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He Y, Miao F, He C, Fan Y, Zhang F, Yang P, Wang M, He J. A Data Mining Study for Analysis of Acupoint Selection and Combinations in Acupuncture Treatment of Carpal Tunnel Syndrome. J Pain Res 2024; 17:1153-1170. [PMID: 38524693 PMCID: PMC10959299 DOI: 10.2147/jpr.s452618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/02/2024] [Indexed: 03/26/2024] Open
Abstract
Background Carpal tunnel syndrome (CTS) is the most prevalent upper limb compressive neuropathy. A considerable number of clinical trials and meta-analyses have provided evidence supporting the effectiveness of acupuncture in treating CTS. Nevertheless, the ideal choice of acupoints remains ambiguous. Objective A data mining analysis was conducted with the objective of determining the most effective acupoint combinations and selection for CTS. Methods A search was conducted across seven Chinese and English electronic bibliographic databases spanning from their inception to March 2023. Selected were clinical trials that evaluated the efficacy of acupuncture therapy for CTS, with or without randomised controlled methods. Data extraction mainly included acupoint prescriptions. Information such as first author, study design and study setting were also extracted. The principal outcomes comprised the clinical manifestations linked to CTS. Statistical descriptions were generated using Excel 2019. The analysis of association rules was conducted using SPSS Modeler 18.0. Using SPSS Statistics 26.0, exploratory factor analysis and cluster analysis were conducted. Results 142 trials (including 86 RCTs and 56 non RCTs) were identified, and 193 groups of effective prescriptions involving 68 acupoints were extracted. The most frequently used acupoints were Da-ling (PC7), Nei-guan (PC6), He-gu (LI4), Wai-guan (TE5), and Yang-xi (LI5). The most frequently used meridians were the pericardial meridian and the large intestine meridian. The majority of special acupoints used were Five-shu points and Yuan-source points, with acupoints on the upper limbs being the most frequently used. The core acupoint groups were analyzed and 11 groups of association rules, 8 factors, and 5 effective cluster groups were obtained. Conclusion The evidence-based acupoint selection and combinations of acupuncture therapy for carpal tunnel syndrome were provided by the findings of this study.
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Affiliation(s)
- Yujun He
- Nancheng Branch Hospital, Ruikang Hospital Affiliated to Guangxi University of Chinese Medicine, Guangxi University of Chinese Medicine, Nanning City, People’s Republic of China
- Faculty of Acupuncture, Moxibustion and Tui Na, Guangxi University of Chinese Medicine, Nanning City, People’s Republic of China
| | - Furui Miao
- Faculty of Acupuncture, Moxibustion and Tui Na, Guangxi University of Chinese Medicine, Nanning City, People’s Republic of China
| | - Cai He
- Nancheng Branch Hospital, Ruikang Hospital Affiliated to Guangxi University of Chinese Medicine, Guangxi University of Chinese Medicine, Nanning City, People’s Republic of China
| | - Yushan Fan
- Faculty of Acupuncture, Moxibustion and Tui Na, Guangxi University of Chinese Medicine, Nanning City, People’s Republic of China
| | - Fangzhi Zhang
- Faculty of Acupuncture, Moxibustion and Tui Na, Guangxi University of Chinese Medicine, Nanning City, People’s Republic of China
| | - Pu Yang
- Graduate School of Guangxi University of Traditional Chinese Medicine, Guangxi University of Chinese Medicine, Nanning City, People’s Republic of China
| | - Miaodong Wang
- Graduate School of Guangxi University of Traditional Chinese Medicine, Guangxi University of Chinese Medicine, Nanning City, People’s Republic of China
| | - Jiujie He
- Faculty of Acupuncture, Moxibustion and Tui Na, Guangxi University of Chinese Medicine, Nanning City, People’s Republic of China
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Sveva V, Farì G, Fai A, Savina A, Viva MG, Agostini F, Ranieri M, Megna M, Mangone M, Paoloni M, Bernetti A. Safety and Efficacy of Ultrasound-Guided Perineural Hydrodissection as a Minimally Invasive Treatment in Carpal Tunnel Syndrome: A Systematic Review. J Pers Med 2024; 14:154. [PMID: 38392587 PMCID: PMC10890373 DOI: 10.3390/jpm14020154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 02/24/2024] Open
Abstract
Ultrasound-guided perineural hydrodissection (HD) is a novel technique that has been found to be effective in providing mechanical release of perineural adhesions and decompression of the nerve, reducing inflammation and edema and restoring its physiological function. It has a significant impact on chronic neuropathic pain (20 ± 4 weeks with VAS < 5 or VAS diminished by 2 points after the procedure). Carpal tunnel syndrome (CTS) is a common entrapment mononeuropathy, and its distribution is typically innervated by the median nerve. Patients with mild or moderate CTS may benefit from nonsurgical treatments or conservative therapies. This review was conducted following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement guidelines. Four investigators assessed each title, abstract, and full-text article for eligibility, with disagreements being resolved by consensus with two experienced investigators. The qualitative assessment of the studies was carried out using the modified Oxford quality scoring system, also known as the modified Jadad score. Furthermore, risk of possible biases was assessed using the Cochrane collaboration tool. The results of this review suggest that US-guided HD is an innovative, effective, well-tolerated, and safe technique (11 out of 923 patients had collateral or side effects after the procedure). However, further studies comparing all drugs and with a larger sample population are required to determine the most effective substance.
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Affiliation(s)
- Valerio Sveva
- Department of Anatomical and Histological Sciences, Legal Medicine and Orthopedics, Sapienza University, 00189 Rome, Italy
| | - Giacomo Farì
- Department of Biological and Environmental Sciences and Technologies (DiSTeBA), Università del Salento, 73100 Lecce, Italy
| | - Annatonia Fai
- Department of Translational Biomedicine and Neuroscience (DiBraiN), Aldo Moro University, 70121 Bari, Italy
| | - Alessio Savina
- Department of Anatomical and Histological Sciences, Legal Medicine and Orthopedics, Sapienza University, 00189 Rome, Italy
| | - Mattia Giuseppe Viva
- Department of Anatomical and Histological Sciences, Legal Medicine and Orthopedics, Sapienza University, 00189 Rome, Italy
| | - Francesco Agostini
- Department of Anatomical and Histological Sciences, Legal Medicine and Orthopedics, Sapienza University, 00189 Rome, Italy
| | - Maurizio Ranieri
- Department of Translational Biomedicine and Neuroscience (DiBraiN), Aldo Moro University, 70121 Bari, Italy
| | - Marisa Megna
- Department of Translational Biomedicine and Neuroscience (DiBraiN), Aldo Moro University, 70121 Bari, Italy
| | - Massimiliano Mangone
- Department of Anatomical and Histological Sciences, Legal Medicine and Orthopedics, Sapienza University, 00189 Rome, Italy
| | - Marco Paoloni
- Department of Anatomical and Histological Sciences, Legal Medicine and Orthopedics, Sapienza University, 00189 Rome, Italy
| | - Andrea Bernetti
- Department of Biological and Environmental Sciences and Technologies (DiSTeBA), Università del Salento, 73100 Lecce, Italy
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Akhmadeeva LR, Davydov OS, Danilov AB, Dukhanin AS, Evzikov GY, Zhivolupov SA, Kukushkin ML, Nikitin SS, Strokov IA, Suponeva NA, Churyukanov MV, Shirokov VA. [A diagnostic algorithm for tunnel mononeuropathies management (consensus of experts)]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:80-88. [PMID: 39072571 DOI: 10.17116/jnevro202412406180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
The expert consensus is aimed to develop an algorithm for the diagnosis and treatment of mononeuropathies for outpatient neurologists. Leading experts in the field of neurology have suggested workup options for certain types of tunnel mononeuropathies based on current data on the effectiveness and safety of various types of conservative and surgical treatment.
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Affiliation(s)
| | - O S Davydov
- Institute of General Pathology and Pathophysiology, Moscow, Russia
| | - A B Danilov
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - A S Dukhanin
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - G Yu Evzikov
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | | | - M L Kukushkin
- Institute of General Pathology and Pathophysiology, Moscow, Russia
| | - S S Nikitin
- Research Centre for Medical Genetics, Moscow, Russia
| | - I A Strokov
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - N A Suponeva
- Research Center of Neurology Moscow, Russi, Research Center of Neurology Moscow, Russia
| | - M V Churyukanov
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - V A Shirokov
- Erisman Federal Scientific Center of Hygiene, Mytishchi, Russia
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Arias-Vázquez PI, Guzzardo MN, Guzzardo DR, Castillo-Avila RG, Tovilla-Zárate CA, Ake Montiel MAN. Efficacy of ozone injections for reducing musculoskeletal pain in comparison with corticosteroid injections: A systematic review and meta-analysis. J Back Musculoskelet Rehabil 2024; 37:821-838. [PMID: 38277280 DOI: 10.3233/bmr-230173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
BACKGROUND Corticosteroid injections are frequently used in the short-term treatment of musculoskeletal pain, but their use is controversial as repeated exposures to corticosteroids can lead to deleterious effects on musculoskeletal tissue. Ozone injections have been proposed as a possible treatment for musculoskeletal pain; however, their effectiveness has not been compared with corticosteroids. OBJECTIVE To evaluate the effectiveness of ozone injections for reducing pain in individuals with musculoskeletal pain in comparison with corticosteroid injections through a meta-analysis. METHODS An online systematic search was performed using electronic databases up to September 2023. We searched for studies that compared corticosteroid injections with ozone injections in the treatment of musculoskeletal pain of diverse origins. RESULTS Eleven studies were included comprising a total of 534 individuals. In the overall pooled analysis, a pain reduction in favor of corticosteroid injections was found in the short term (d= 0.31, 95% CI 0.01 to 0.60, p (z) 0.04, I2 = 32%). In the medium term, no significant differences were found in reducing pain between groups (d=-0.17, 95% CI -0.42 to 0.07, p (z) 0.15, I2 = 0%). CONCLUSIONS Our results suggest that corticosteroids injections are more effective in reducing musculoskeletal pain in the short term, but equally effective in the medium term when compared with ozone injections. Nonetheless, better-quality clinical trials are necessary to corroborate these results.
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Affiliation(s)
| | - Mauro Nicolás Guzzardo
- Team of Formation and Research in Pain (EFID in Spanish), National University of Rosario, Rosario, Argentina
| | - Duilio Román Guzzardo
- Team of Formation and Research in Pain (EFID in Spanish), National University of Rosario, Rosario, Argentina
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Zhou T, Wu Z, Gou X, Xia H, Ding J, Ai S. Local injection therapy for carpal tunnel syndrome: a network meta-analysis of randomized controlled trial. Front Pharmacol 2023; 14:1140410. [PMID: 37693911 PMCID: PMC10484596 DOI: 10.3389/fphar.2023.1140410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Objective: Clinical research has shown that local injections for carpal tunnel syndrome reduce the symptoms of patients and enhance their quality of life considerably. However, there are several therapy options, and the optimal choice of regimen remains uncertain. Therefore, we comprehensively evaluated the variations in clinical efficacy and safety of several medications for treating carpal tunnel syndrome. Methods: Computer searches of Embase, PubMed, Cochrane Library, and Web of Science databases were used to collect articles of randomized controlled trials on local injections for treating carpal tunnel syndrome from database creation till 10 June 2023. Two researchers independently screened the literature, extracted information, evaluated the risk of bias in the included studies, and performed network Meta-analysis using Stata 17.0 software. Drug efficacy was assessed using symptom severity/function and pain intensity. Surface under the cumulative ranking curve (SUCRA) ranking was used to determine the advantage of each therapy. Results: We included 26 randomized controlled trials with 1896 wrists involving 12 interventions, such as local injections of corticosteroids, platelet-rich plasma, 5% dextrose, progesterone, and hyaluronidase. The results of the network meta-analysis showed the following: (i) symptom severity: at the 3-month follow-up, D5W combined with splinting (SUCRA = 95%) ranked first, and hyaluronidase (SUCRA = 89.6%) at 6 months; (ii) functional severity: either at the 3-month follow-up (SUCRA = 89.5%) or 6 months (SUCRA = 83.6%), iii) pain intensity: 5% dextrose in water combined with splinting was the most effective at the 3-month (SUCRA = 85%) and 6-month (SUCRA = 87.6%) follow-up. Conclusion: Considering the combination of symptoms/function and pain intensity, combining 5% dextrose in water with splinting is probably the treatment of choice for patients with carpal tunnel syndrome. It is more effective than glucocorticoids and no adverse effects have been observed. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022370525.
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Affiliation(s)
- TianQi Zhou
- College of Health and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - ZhuoRao Wu
- College of Health and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - XingYun Gou
- College of Health and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - HaiSha Xia
- College of Health and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - JiLin Ding
- Department of Rehabilitation Medicine, Mianyang Hospital, Chengdu University of Traditional Chinese Medicine, Mianyang, China
| | - ShuangChun Ai
- College of Health and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
- Department of Rehabilitation Medicine, Mianyang Hospital, Chengdu University of Traditional Chinese Medicine, Mianyang, China
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He Y, Miao F, Fan Y, Zhang F, Yang P, Zhao X, Wang M, He C, He J. Analysis of Acupoint Selection and Combinations in Acupuncture Treatment of Carpal Tunnel Syndrome: A Protocol for Data Mining. J Pain Res 2023; 16:1941-1948. [PMID: 37312834 PMCID: PMC10258040 DOI: 10.2147/jpr.s411843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/25/2023] [Indexed: 06/15/2023] Open
Abstract
Background Carpal tunnel syndrome (CTS), as the most common compression neuropathy in the upper limb, can lead to upper limb dysfunction in patients. The effectiveness of acupuncture in treating CTS has been validated based on numerous clinical trials and meta-analyses, but questions remain, such as how to select the best acupoints. Our purpose is to conduct the first data mining analysis to identify the most effective acupoint selection and combinations for treating CTS. Methods We will search 7 electronic bibliographic databases (PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang Database, Chinese Biomedical Literature Database and Chongqing VIP Database) from inception to March 2023. Clinical trials assessing the effectiveness of acupuncture therapy on the management of CTS will be selected. Reviews, protocols, animal trials, case reports, systematic reviews, and meta-analyses will be excluded. The primary outcome measure will be clinical result associated with CTS. Descriptive statistics will be performed in Excel 2019. Association rule analysis will be performed in SPSS Modeler 18.0. Exploratory factor analysis and cluster analysis will be performed in SPSS Statistics 26.0. Results This study will investigate the most effective acupoint selection and combinations for patients with CTS. Conclusion Our findings will provide evidence for the effectiveness and potential treatment prescriptions of acupoint application for patients with CTS, helping clinicians and patients make a more informed decision together.
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Affiliation(s)
- Yujun He
- Faculty of Acupuncture, Moxibustion and Tui Na, Guangxi University of Chinese Medicine, Nanning, People’s Republic of China
| | - Furui Miao
- Faculty of Acupuncture, Moxibustion and Tui Na, Guangxi University of Chinese Medicine, Nanning, People’s Republic of China
| | - Yushan Fan
- Faculty of Acupuncture, Moxibustion and Tui Na, Guangxi University of Chinese Medicine, Nanning, People’s Republic of China
| | - Fangzhi Zhang
- Faculty of Acupuncture, Moxibustion and Tui Na, Guangxi University of Chinese Medicine, Nanning, People’s Republic of China
| | - Pu Yang
- Graduate School, Guangxi University of Chinese Medicine, Nanning, People’s Republic of China
| | - Xinyi Zhao
- Guangxi Zhuang Yao Medicine Center of Engineering and Technology, Guangxi University of Chinese Medicine, Nanning, People’s Republic of China
| | - Miaodong Wang
- Graduate School, Guangxi University of Chinese Medicine, Nanning, People’s Republic of China
| | - Cai He
- Faculty of Acupuncture, Moxibustion and Tui Na, Guangxi University of Chinese Medicine, Nanning, People’s Republic of China
| | - Jiujie He
- Faculty of Acupuncture, Moxibustion and Tui Na, Guangxi University of Chinese Medicine, Nanning, People’s Republic of China
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Omole AE, Awosika A, Khan A, Adabanya U, Anand N, Patel T, Edmondson CK, Fakoya AO, Millis RM. An Integrated Review of Carpal Tunnel Syndrome: New Insights to an Old Problem. Cureus 2023; 15:e40145. [PMID: 37304388 PMCID: PMC10250024 DOI: 10.7759/cureus.40145] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2023] [Indexed: 06/13/2023] Open
Abstract
Carpal tunnel syndrome (CTS) is a common entrapment neuropathy characterized by pain, numbness, and impaired function of the hand due to compression of the median nerve at the level of the wrist. Although CTS can develop from repetitive strain, injury, or medical conditions, there are also congenital and genetic risk factors that can predispose individuals to the condition. With respect to anatomical factors, some individuals are born with a smaller carpal tunnel, which increases their susceptibility to median nerve compression. Variations in specific genes, such as those encoding proteins involved in extracellular matrix remodeling, inflammation, and nerve function, have also been linked to an increased risk for CTS. CTS is associated with a high cost of health care maintenance and loss of work productivity. Therefore, it is vital that primary care physicians fully understand the anatomy, epidemiology, pathophysiology, etiology, and risk factors of CTS, so they can be proactive in prevention, diagnosing, and guiding proper treatment. This integrated review also provides insights into how biological, genetic, environmental, and occupational factors interact with structural elements to determine who is most likely to acquire and suffer from CTS. Keeping health practitioners abreast of all the factors that could impact CTS should go a long way in decreasing the health care and socioeconomic burden of CTS.
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Affiliation(s)
- Adekunle E Omole
- Anatomical Sciences, American University of Antigua, Saint John, ATG
| | - Ayoola Awosika
- College of Medicine, University of Illinois, Chicago, USA
| | - Anosh Khan
- Emergency Medicine, Spartan Health Sciences University, Vieux Fort, LCA
| | | | - Nikhilesh Anand
- Pharmacology, American University of Antigua, Saint John, ATG
| | - Tirath Patel
- Surgery, American University of Antigua, Saint John, ATG
| | | | - Adegbenro O Fakoya
- Cellular Biology and Anatomy, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Richard M Millis
- Pathophysiology, American University of Antigua, Saint John, ATG
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Karjalainen TV, Lusa V, Page MJ, O'Connor D, Massy-Westropp N, Peters SE. Splinting for carpal tunnel syndrome. Cochrane Database Syst Rev 2023; 2:CD010003. [PMID: 36848651 PMCID: PMC9969978 DOI: 10.1002/14651858.cd010003.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Carpal tunnel syndrome (CTS) is a compression neuropathy of the median nerve causing pain and numbness and tingling typically in the thumb, index and middle finger. It sometimes results in muscle wasting, diminished sensitivity and loss of dexterity. Splinting the wrist (with or without the hand) using an orthosis is usually offered to people with mild-to-moderate findings, but its effectiveness remains unclear. OBJECTIVES To assess the effects (benefits and harms) of splinting for people with CTS. SEARCH METHODS On 12 December 2021, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, AMED, CINAHL, ClinicalTrials.gov, and WHO ICTRP with no limitations. We checked the reference lists of included studies and relevant systematic reviews for studies. SELECTION CRITERIA Randomised trials were included if the effect of splinting could be isolated from other treatment modalities. The comparisons included splinting versus no active treatment (or placebo), splinting versus another disease-modifying non-surgical treatment, and comparisons of different splint-wearing regimens. We excluded studies comparing splinting with surgery or one splint design with another. We excluded participants if they had previously undergone surgical release. DATA COLLECTION AND ANALYSIS Review authors independently selected trials for inclusion, extracted data, assessed study risk of bias and the certainty in the body of evidence for primary outcomes using the GRADE approach, according to standard Cochrane methodology. MAIN RESULTS We included 29 trials randomising 1937 adults with CTS. The trials ranged from 21 to 234 participants, with mean ages between 42 and 60 years. The mean duration of CTS symptoms was seven weeks to five years. Eight studies with 523 hands compared splinting with no active intervention (no treatment, sham-kinesiology tape or sham-laser); 20 studies compared splinting (or splinting delivered along with another non-surgical intervention) with another non-surgical intervention; and three studies compared different splinting regimens (e.g. night-time only versus full time). Trials were generally at high risk of bias for one or more domains, including lack of blinding (all included studies) and lack of information about randomisation or allocation concealment in 23 studies. For the primary comparison, splinting compared to no active treatment, splinting may provide little or no benefits in symptoms in the short term (< 3 months). The mean Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (SSS) (scale 1 to 5, higher is worse; minimal clinically important difference (MCID) 1 point) was 0.37 points better with splint (95% confidence interval (CI) 0.82 better to 0.08 worse; 6 studies, 306 participants; low-certainty evidence) compared with no active treatment. Removing studies with high or unclear risk of bias due to lack of randomisation or allocation concealment supported our conclusion of no important effect (mean difference (MD) 0.01 points worse with splint; 95% CI 0.20 better to 0.22 worse; 3 studies, 124 participants). In the long term (> 3 months), we are uncertain about the effect of splinting on symptoms (mean BCTQ SSS 0.64 better with splinting; 95% CI 1.2 better to 0.08 better; 2 studies, 144 participants; very low-certainty evidence). Splinting probably does not improve hand function in the short term and may not improve hand function in the long term. In the short term, the mean BCTQ Functional Status Scale (FSS) (1 to 5, higher is worse; MCID 0.7 points) was 0.24 points better (95% CI 0.44 better to 0.03 better; 6 studies, 306 participants; moderate-certainty evidence) with splinting compared with no active treatment. In the long term, the mean BCTQ FSS was 0.25 points better (95% CI 0.68 better to 0.18 worse; 1 study, 34 participants; low-certainty evidence) with splinting compared with no active treatment. Night-time splinting may result in a higher rate of overall improvement in the short term (risk ratio (RR) 3.86, 95% CI 2.29 to 6.51; 1 study, 80 participants; number needed to treat for an additional beneficial outcome (NNTB) 2, 95% CI 2 to 2; low-certainty evidence). We are uncertain if splinting decreases referral to surgery, RR 0.47 (95% CI 0.14 to 1.58; 3 studies, 243 participants; very low-certainty evidence). None of the trials reported health-related quality of life. Low-certainty evidence from one study suggests that splinting may have a higher rate of adverse events, which were transient, but the 95% CIs included no effect. Seven of 40 participants (18%) reported adverse effects in the splinting group and 0 of 40 participants (0%) in the no active treatment group (RR 15.0, 95% CI 0.89 to 254.13; 1 study, 80 participants). There was low- to moderate-certainty evidence for the other comparisons: splinting may not provide additional benefits in symptoms or hand function when given together with corticosteroid injection (moderate-certainty evidence) or with rehabilitation (low-certainty evidence); nor when compared with corticosteroid (injection or oral; low certainty), exercises (low certainty), kinesiology taping (low certainty), rigid taping (low certainty), platelet-rich plasma (moderate certainty), or extracorporeal shock wave treatment (moderate certainty). Splinting for 12 weeks may not be better than six weeks, but six months of splinting may be better than six weeks of splinting in improving symptoms and function (low-certainty evidence). AUTHORS' CONCLUSIONS There is insufficient evidence to conclude whether splinting benefits people with CTS. Limited evidence does not exclude small improvements in CTS symptoms and hand function, but they may not be clinically important, and the clinical relevance of small differences with splinting is unclear. Low-certainty evidence suggests that people may have a greater chance of experiencing overall improvement with night-time splints than no treatment. As splinting is a relatively inexpensive intervention with no plausible long-term harms, small effects could justify its use, particularly when patients are not interested in having surgery or injections. It is unclear if a splint is optimally worn full time or at night-time only and whether long-term use is better than short-term use, but low-certainty evidence suggests that the benefits may manifest in the long term.
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Affiliation(s)
- Teemu V Karjalainen
- Department of Surgery, Hospital Nova of Central Finland, Central Finland Healthcare District, Jyväskylä, Finland
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, 3144, Australia
| | - Vieda Lusa
- Hospital Nova of Central Finland, Central Finland Healthcare District, Jyväskylä, Finland
| | - Matthew J Page
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Denise O'Connor
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, 3004, Australia
| | | | - Susan E Peters
- Center for Work, Health, and Well-being, Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, Boston, USA
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Ashworth NL, Bland JDP, Chapman KM, Tardif G, Albarqouni L, Nagendran A. Local corticosteroid injection versus placebo for carpal tunnel syndrome. Cochrane Database Syst Rev 2023; 2:CD015148. [PMID: 36722795 PMCID: PMC9891198 DOI: 10.1002/14651858.cd015148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
| | - Jeremy D P Bland
- Electroencephalography (EEG) Department, East Kent Hospitals University NHS Trust, Canterbury, UK
| | - Kristine M Chapman
- Neuromuscular Disease Unit, Diamond Health Care Centre, Vancouver, Canada
| | - Gaetan Tardif
- Division of Physical Medicine & Rehabilitation, University of Toronto, Toronto, Canada
| | - Loai Albarqouni
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Arjuna Nagendran
- Department of Clinical Neurophysiology, National Hospital for Neurology and Neurosurgery, London, UK
- Department of Clinical Neurophysiology, London North West University Healthcare NHS Trust, London, UK
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Park HY, Kim JM, Kim IJ, Kang M, Ham JR, Nam YS. Cadaveric Study of Thread Carpal Tunnel Release Using Newly Developed Thread, With a Histologic Perspective. Ann Rehabil Med 2023; 47:19-25. [PMID: 36635884 PMCID: PMC10020053 DOI: 10.5535/arm.22130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/05/2022] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To examine the usefulness and feasibility of modified thread carpal tunnel release (TCTR) by comparing the results of using pre-existing commercial thread with those of a newly developed thread (Smartwire-01). METHODS A total of 17 cadaveric wrists were used in the study. The modified TCTR method was practiced by two different experts. Pre-existing commercial surgical dissecting thread (Loop&ShearTM) was used for five wrists and the newly developed Smartwire-01 was used for twelve wrists. The gross and microanatomy of the specimens were evaluated by a blinded anatomist. RESULTS Both types of thread were able to cut the TCL similarly. Gross anatomy and histologic findings showed that there was no significant difference between the two types of threads. However, the practitioners felt that it was easier to cut the TCL using the newly-developed thread. CONCLUSION TCTR using Smartwire-01 was as effective as pre-existing Loop&ShearTM, with better user experiences.
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Affiliation(s)
- Hae-Yeon Park
- Department of Rehabilitation Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Min Kim
- Department of Rehabilitation Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Jong Kim
- Department of Rehabilitation Medicine, Howareyou Rehabilitation Clinic, Seoul, Korea
| | - Minsuk Kang
- Department of Rehabilitation Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Ryul Ham
- Department of Research & Development, Ultra V Co. Ltd., Seoul, Korea
| | - Yong Seok Nam
- Department of Anatomy, College of Korean Medicine, Dongshin University, Naju, Korea
- Corresponding author: Yong Seok Nam Department of Anatomy, College of Korean Medicine, Dongshin University, 67 Dongsindae-gil, Naju 58245, Korea. Tel: +82-61-350-3317, Fax: +82-61- 330-3519, E-mail:
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11
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Nasiri A, Rezaei Motlagh F, Vafaei MA. Efficacy comparison between ultrasound-guided injections of 5% dextrose with corticosteroids in carpal tunnel syndrome patients. Neurol Res 2023; 45:554-563. [PMID: 36617808 DOI: 10.1080/01616412.2022.2164453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND There is no standard guideline for treating mild to moderate carpal tunnel syndrome (CTS). 5% dextrose perineural injection has been a potential and innovative treatment with long-term effects for CTS; however, there is few published randomized clinical trial comparing the efficacy of 5% dextrose perineural injection versus corticosteroid injection in treating CTS. MATERIALS AND METHODS In this double-blinded randomized active-controlled trial, we randomly allocated 1 session of either 2 cc 5% dextrose or 1 cc methylprednisolone acetate mixed with 1 cc normal saline in 36 patients with mild to moderate CTS of single or both their wrists. The baseline VAS, BCTQ, electrophysiological studies, and sonography assessment of median nerve CSA were carried out at the baseline and 1-month and 3-month follow-ups, as well as recording demographic variables. RESULTS A statistically significant decreasing trend in VAS (P < 0.0001), BCTQ-ss (P < 0.0001), median nerve CSA (P = 0.05), SNAP-PL (P < 0.0001), and CMAP-OL (P = 0.048) in both methylprednisolone and 5% dextrose groups was observed. No significant difference was observed in slope of the trend of studied parameters, including VAS (P = 0.95), BCTQ-ss (P = 0.88), BCTQ-F (P = 0.34), median nerve CSA (P = 0.321), SNAP-PL (P = 0.9), CMAP-OL (P = 0.799), SNAP-amplitude (P = 0.798), and CMAP-amplitude (P = 0.584). CONCLUSION 5% dextrose perineural injection is an effective and safe treatment for mild to moderate CTS, in comparison with the short-term results attained from corticosteroids. Further randomized clinical trials with longer follow-up periods are warranted.
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Affiliation(s)
- Aref Nasiri
- Department of Physical Medicine and Rehabilitation, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farzaneh Rezaei Motlagh
- Department of Physical Medicine and Rehabilitation, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Amin Vafaei
- Department of Physical Medicine and Rehabilitation, Shiraz University of Medical Sciences, Shiraz, Iran
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12
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Effect of ultrasound-guided versus landmark-guided local corticosteroid injection for carpal tunnel syndrome: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2023; 143:545-561. [PMID: 35635576 DOI: 10.1007/s00402-022-04437-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/26/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Carpal tunnel syndrome (CTS), the commonest neuropathy of the upper limb, can be managed with different therapeutic approaches. Local corticosteroid injection has been adopted widely in clinical practice, as it showed great efficacy in treating CTS. However, the best injection technique continues to be a subject of controversy. The aim of this systematic review and meta-analysis was to evaluate the efficacy of ultrasound-guided (US-guided) versus landmark-guided (LM-guided) corticosteroid injection on the clinical and electrophysiological outcomes in patients with CTS. METHODS We performed a systematic literature search in Medline, Embase, and CENTRAL, from which we included randomized controlled trials (RCTs) that compared US-guided and LM-based corticosteroid injection in treating individuals with CTS. We evaluated the following outcomes: Boston carpal tunnel questionnaire functional status scale (BCTQ-FSS) and symptom severity scale (BCTQ-SSS), and adverse event rate. The standardized mean difference (SMD) was used to represent continuous outcomes, while the risk ratio (RR) was used to represent dichotomous outcome. RESULTS A total of 8 RCTs that enrolled 500 wrists were deemed eligible. US-guided injection showed a significantly better BCTQ-FSS (SMD = -0.22, 95% CI -0.39 to -0.04), BCTQ-SSS (SMD = -0.77, 95% CI -1.22 to -0.31), and adverse event rate (RR = 0.32, 95% CI 0.21 to 0.49) compared to LM-based injection. CONCLUSION This meta-analysis showed the superiority of US-guided corticosteroid injection over LM-guided corticosteroid injection in enhancing functional status, improving symptom severity, and reducing the adverse event rate in individuals with CTS.
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13
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Kang BH, Woo SR, Park HJ, Chung SY, Kang S, Jeong SH, Yoon JS. Ultrasonographic Assessment of the Safe Zone for Carpal Tunnel Intervention: A Comparison Between Healthy Individuals and Patients With Carpal Tunnel Syndrome. Ann Rehabil Med 2022; 46:284-291. [PMID: 36588443 PMCID: PMC9810651 DOI: 10.5535/arm.22123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 10/11/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To compare transverse and longitudinal safe zones using ultrasonography between healthy individuals and patients with carpal tunnel syndrome (CTS). METHODS This was a prospective observational case-control study. Forty wrists from 20 healthy individuals and 40 wrists from 24 patients with CTS were examined. Patients with CTS were classified into three groups (mild, moderate, and severe CTS) based on electrodiagnostic findings. Using ultrasonography, we measured the distance between the median nerve and ulnar vessels to identify the transverse safe zone, and between the distal flexor retinaculum and superficial palmar artery arch to identify the longitudinal safe zone. RESULTS The transverse and longitudinal safe zones were significantly different between participants with CTS and those without CTS. The transverse safe zone significantly differed between the mild and severe CTS groups, while the longitudinal safe zone was not significantly different between the groups. The cross-sectional area of the median nerve negatively correlated with the transverse and longitudinal safe zones. CONCLUSION Transverse and longitudinal safe zones were narrower in patients with CTS than in the healthy group. A significant difference was observed between patients with mild CTS and those with severe CTS. Furthermore, the cross-sectional area of the median nerve was directly proportional to the degree of narrowing of the transverse and longitudinal safe zones.
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Affiliation(s)
- Byung Heon Kang
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
| | - Sang Rok Woo
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
| | - Hyun Jin Park
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
| | - Seong Yun Chung
- Goodbone Physical Medicine and Rehabilitation Clinic, Seoul, Korea
| | - Seok Kang
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
| | - Seong-Ho Jeong
- Department of Plastic and Reconstructive Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Joon Shik Yoon
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea,Corresponding author: Joon Shik Yoon Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea. Tel: +82-2-2626- 1500, Fax: +82-2-859-5422, E-mail:
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14
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How to Differentiate Pronator Syndrome from Carpal Tunnel Syndrome: A Comprehensive Clinical Comparison. Diagnostics (Basel) 2022; 12:diagnostics12102433. [PMID: 36292122 PMCID: PMC9600501 DOI: 10.3390/diagnostics12102433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/17/2022] Open
Abstract
The diagnostic process that allows pronator syndrome to be differentiated reliably from carpal tunnel syndrome remains a challenge for clinicians, as evidenced by the most common cause of pronator syndrome misdiagnosis: carpal tunnel syndrome. Pronator syndrome can be caused by compression of the median nerve as it passes through the anatomical structures of the forearm, while carpal tunnel syndrome refers to one particular topographic area within which compression occurs, the carpal tunnel. The present narrative review is a complex clinical comparison of the two syndromes with their anatomical backgrounds involving topographical relationships, morphology, clinical picture, differential diagnosis, and therapeutic options. It discusses the most frequently used diagnostic techniques and their correct interpretations. Its main goal is to provide an up-to-date picture of the current understanding of the disease processes and their etiologies, to establish an appropriate diagnosis, and introduce relevant treatment benefiting the patient.
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15
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Martin-Vega FJ, Vinolo-Gil MJ, Perez-Cabezas V, Rodríguez-Huguet M, Garcia-Munoz C, Gonzalez Medina G. Use of Sonophoresis with Corticosteroids in Carpal Tunnel Syndrome: Systematic Review and Meta-Analysis. J Pers Med 2022; 12:jpm12071160. [PMID: 35887657 PMCID: PMC9325114 DOI: 10.3390/jpm12071160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/13/2022] [Accepted: 07/15/2022] [Indexed: 11/26/2022] Open
Abstract
Carpal tunnel syndrome is a neuropathic disease. It is one of the most frequent musculoskeletal pathologies affecting the upper limbs. One of most frequently used non-surgical treatments is corticosteorids. There are several alternatives for corticosteroids administration. One of them is phonophoresis, this being an effective and painless method of treatment. A systematic review and meta-analysis have been conducted over the use of phonophoresis with corticosteroids for the treatment of carpal tunnel syndrome compared to other non-surgical treatment methods. Keywords from Medical Subjects Headings (MeSH) were used in the following databases: Wos, Scopus, CINHAL, SciELO and PeDro. A total of 222 potentially relevant articles were retrieved. Eleven articles analysing the efficacy of phonophoresis with corticosteroids in reducing pain symptoms in individuals with carpal tunnel syndrome were included, 10 of which were used to conduct the meta-analysis. A conclusion could not be reached as to the application of phonophoresis with corticosteroids being better than other treatment methods, except for the perception of pain and an improved motor and sensory nerve conduction in cases of mild to moderate carpal tunnel syndrome.
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Affiliation(s)
- Francisco Javier Martin-Vega
- Department of Nursing and Physiotherapy, University of Cadiz, 11009 Cadiz, Spain; (F.J.M.-V.); (V.P.-C.); (M.R.-H.); (C.G.-M.); (G.G.M.)
| | - Maria Jesus Vinolo-Gil
- Department of Nursing and Physiotherapy, University of Cadiz, 11009 Cadiz, Spain; (F.J.M.-V.); (V.P.-C.); (M.R.-H.); (C.G.-M.); (G.G.M.)
- Rehabilitation Clinical Management Unit, Interlevels-Intercenters Hospital Puerta del Mar, Hospital Puerto Real, Cadiz Bay-La Janda Health District, 11006 Cadiz, Spain
- Correspondence:
| | - Veronica Perez-Cabezas
- Department of Nursing and Physiotherapy, University of Cadiz, 11009 Cadiz, Spain; (F.J.M.-V.); (V.P.-C.); (M.R.-H.); (C.G.-M.); (G.G.M.)
| | - Manuel Rodríguez-Huguet
- Department of Nursing and Physiotherapy, University of Cadiz, 11009 Cadiz, Spain; (F.J.M.-V.); (V.P.-C.); (M.R.-H.); (C.G.-M.); (G.G.M.)
| | - Cristina Garcia-Munoz
- Department of Nursing and Physiotherapy, University of Cadiz, 11009 Cadiz, Spain; (F.J.M.-V.); (V.P.-C.); (M.R.-H.); (C.G.-M.); (G.G.M.)
| | - Gloria Gonzalez Medina
- Department of Nursing and Physiotherapy, University of Cadiz, 11009 Cadiz, Spain; (F.J.M.-V.); (V.P.-C.); (M.R.-H.); (C.G.-M.); (G.G.M.)
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Poenaru D, Ojoga F, Sandulescu M, Cinteza D. Conservative therapy in ulnar neuropathy at the elbow (Review). Exp Ther Med 2022; 24:517. [PMID: 35837045 PMCID: PMC9257949 DOI: 10.3892/etm.2022.11444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Ulnar neuropathy at the elbow (UNE) is the second most frequent entrapment syndrome in the upper limb after carpal tunnel syndrome. Clinical features are validated through electromyographic and sonographic examination. Although the two aforementioned entrapment syndromes share common pathophysiological traits, the conservative treatment approach for mild and moderate cases of UNE differs from that for median nerve entrapment. The present study identified 23 different types of scientific articles aimed to address this issue. The research stressed the importance of patient education and activity modification. Night splinting offers clinical and functional improvement. Although corticosteroid injections play a role in selected cases, their utility remains to be validated. Physiotherapy trials evaluated ultrasound, low-level laser therapy, diathermy, extracorporeal shock wave therapy and dry cupping. Neurodynamic mobilization may add value to therapeutic approaches and should be a part of it.
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Affiliation(s)
- Daniela Poenaru
- Department of Rehabilitation, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest 052785, Romania
| | - Florina Ojoga
- Department of Rehabilitation, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest 052785, Romania
| | - Miruna Sandulescu
- Department of Rehabilitation, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest 052785, Romania
| | - Delia Cinteza
- Department of Rehabilitation, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest 052785, Romania
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17
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Harhaus L, Daeschler SC, Aman M, Böcker AH, Klimitz F, Bickert B. [Differential therapeutic Approaches in Treatment of Carpal Tunnel Syndrome]. HANDCHIR MIKROCHIR P 2022; 54:236-243. [PMID: 35688431 DOI: 10.1055/a-1839-8297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Carpal tunnel syndrome (CTS) is one of the most common compression neuropathies. The therapeutic concept should be tailored to each patient individually, with initial non-surgical treatment being the standard of care for early CTS. Primary surgical intervention should be considered in more advanced diseases stages, in case of concomitant pathologies (including space-occupying lesions, complex regional pain syndrome or diabetic neuropathy), if non-surgical strategies have failed or in pregnancy-related CTS. This work aims to discuss common surgical approaches, their clinical application as well as benefits and disadvantages in a pragmatic style. Further, we highlight surgical strategies to address recurrent CTS following failed primary surgery. In view of the recently updated S3 guidelines "Diagnosis and Therapy of Carpal Tunnel Syndrome", this topic is timely and relevant for hand and nerve surgeons.
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Affiliation(s)
- Leila Harhaus
- BG Unfallklinik Ludwigshafen Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische Chirurgie der Universität Heidelberg
| | - Simeon C Daeschler
- BG Unfallklinik Ludwigshafen Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische Chirurgie der Universität Heidelberg
| | - Martin Aman
- BG Unfallklinik Ludwigshafen Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische Chirurgie der Universität Heidelberg
| | - Arne Hendrik Böcker
- BG Unfallklinik Ludwigshafen Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische Chirurgie der Universität Heidelberg
| | - Felix Klimitz
- BG Unfallklinik Ludwigshafen Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische Chirurgie der Universität Heidelberg
| | - Berthold Bickert
- BG Unfallklinik Ludwigshafen Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische Chirurgie der Universität Heidelberg
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Local Corticosteroid Injections versus Surgical Carpal Tunnel Release for Carpal Tunnel Syndrome: Systematic Review and Meta-Analysis. Life (Basel) 2022; 12:life12040533. [PMID: 35455023 PMCID: PMC9026554 DOI: 10.3390/life12040533] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 11/17/2022] Open
Abstract
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.
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He JJ, Wei XM, Dou ZL, Zhang JS, Wei ZH, Zhang WX, Jiang L. Ultrasound-Guided Nerve Hydrodissection With 5% Dextrose 4 Weeks After Steroid Injection in Treatment of Carpal Tunnel Syndrome: A Retrospective Study. Front Neurol 2022; 12:782319. [PMID: 35197913 PMCID: PMC8859306 DOI: 10.3389/fneur.2021.782319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/24/2021] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo investigate the efficacy and safety of ultrasound-guided nerve hydrodissection (HD) with 5% dextrose (D5W) as add-on therapy after corticosteroid injection in carpal tunnel syndrome (CTS), and provide a novel strategy.MethodsIn this retrospective study, patients with CTS who received ultrasound-guided nerve HD with D5W as add-on therapy after corticosteroid injection (combination group) were enrolled. Patients who received corticosteroid injection without add-on therapy (steroid group) were recruited as the control group. Ultrasound-guided nerve HD with D5W was performed 4 weeks after corticosteroid injection. Treatment effectiveness were assessed by visual analog scale (VAS) and Boston Carpal Tunnel Syndrome Questionnaire (BCTQ). The assessment was performed at baseline and 4, 8, and 12 weeks after corticosteroid injection. In addition, adverse events were recorded in this study.ResultsA total of 49 patients and 62 wrists meeting the criteria were included, with 24 patients and 31 wrists in the steroid group and 25 patients and 31 wrists in the combination group. Compared with baseline data, both groups showed greater improvement in VAS, BCTQs (BCTQ severity), and BCTQf (BCTQ function) at 4, 8, and 12 weeks follow-up. VAS, BCTQs, and BCTQf scores at baseline and week 4 were comparable between steroid group and combination group. Compared with steroid group, combination group exhibited a significant reduction in VAS, BCTQs, and BCTQf at 8- and 12-week follow-up (P ≤ 0.01). No adverse event occurred in any group.ConclusionsOur results showed that ultrasound-guided nerve HD with D5W as add-on therapy after corticosteroid injection was efficacious and safe in CTS, and combination therapy is more beneficial than corticosteroid monotherapy in the improvement of symptoms and function at 8- and 12-week follow-up.
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Affiliation(s)
- Juan-juan He
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
- Department of Rehabilitation, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiao-mei Wei
- Department of Rehabilitation, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zu-lin Dou
- Department of Rehabilitation, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiang-shan Zhang
- Department of Rehabilitation, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhen-hai Wei
- Department of Rehabilitation, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei-xi Zhang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
- *Correspondence: Wei-xi Zhang
| | - Li Jiang
- Department of Rehabilitation, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Rehabilitation, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Li Jiang
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20
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Wang JC, Hsu PC, Wang KA, Chang KV. Ultrasound-Guided Triamcinolone Acetonide Hydrodissection for Carpal Tunnel Syndrome: A Randomized Controlled Trial. Front Med (Lausanne) 2021; 8:742724. [PMID: 34589506 PMCID: PMC8475784 DOI: 10.3389/fmed.2021.742724] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/19/2021] [Indexed: 12/27/2022] Open
Abstract
Background: Despite the wide use of corticosteroid hydrodissection for carpal tunnel syndrome (CTS), there is insufficient evidence to confirm its efficacy. This study aimed to compare the effectiveness of corticosteroid hydrodissection vs. corticosteroid perineural injection alone on clinical and electrophysiological parameters in patients with CTS. Method: This prospective randomized controlled trial (RCT) was conducted in a tertiary care center with a follow-up period of 12 weeks. Subjects were randomly assigned to either ultrasound-guided hydrodissection with a mixture of 1 mL of triamcinolone acetonide (10 mg/mL), 1 mL of 2% lidocaine, and 8 mL normal saline or ultrasound-guided perineural injection with 1 mL of triamcinolone acetonide (40 mg/mL) and 1 mL of 2% lidocaine. The primary outcome measure was the symptom severity subscale (SSS) of Boston Carpal Tunnel Questionnaire (BCTQ) scores at baseline and at 6 and 12 weeks' post-treatment. The secondary outcomes included the functional status subscale (FSS) of BCTQ and the distal motor latency and sensory nerve conduction velocity of the median nerve. The effect of interventions on the designated outcome was analyzed using a 3 × 2 repeated measures analysis of variance. The within-subject and among-subject factors were differences in time (before the intervention, and 6 and 12 weeks after injection) and intervention types (with or without hydrodissection), respectively. Results: Sixty-four patients diagnosed with CTS were enrolled. Both groups experienced improvement in the SSS and FSS of BCTQ and median nerve distal motor latency and sensory nerve conduction velocity. However, group-by-time interactions were not significant in any outcome measurements. No serious adverse events were reported in either group, except for two patients in the hydrodissection group who reported minor post-injection pain on the first day after the intervention, which resolved spontaneously without the need for additional treatments. Conclusion: Hydrodissection did not provide an additional benefit compared to corticosteroid perineural injection alone. More prospective studies are needed to investigate the long-term effectiveness of corticosteroid hydrodissection, as well as its influence on median nerve mobility.
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Affiliation(s)
- Jia-Chi Wang
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Cheng Hsu
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kevin A Wang
- Division of General Surgery, Department of Surgery, Shin-Kong Memorial Hospital, Taipei, Taiwan.,School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation and Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch and National Taiwan University College of Medicine, Taipei, Taiwan.,Center for Regional Anesthesia and Pain Medicine, Wang-Fang Hospital, Taipei Medical University, Taipei, Taiwan
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21
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Meems M, Boekhorst MGBM, Pop VJM. Long-Term Follow-Up Results of Mechanical Wrist Traction as Non-Invasive Treatment for Carpal Tunnel Syndrome. Front Neurol 2021; 12:668549. [PMID: 34552548 PMCID: PMC8450522 DOI: 10.3389/fneur.2021.668549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 07/14/2021] [Indexed: 11/13/2022] Open
Abstract
Background: For patients with carpal tunnel syndrome (CTS), the only long-term effective treatment option is carpal tunnel release surgery. Up to one-third report recurrent symptoms, and 12% needs repeated surgery. This study aimed to evaluate the long-term effects of mechanical traction as a non-invasive treatment option for CTS compared to care as usual. Methods: Patients with electrodiagnostically confirmed CTS [N = 181; mean age, 58.1 (13.0) years; 67% women] were recruited from an outpatient neurology clinic in the Netherlands. Patients completed baseline questionnaires and randomized to the intervention group (12 treatments with mechanical traction, twice a week for 6 weeks) or care as usual. The primary clinical outcome measure was surgery during the 12-month follow-up. Secondly, we assessed symptom severity with the Boston Carpal Tunnel Questionnaire (BCTQ) at baseline and at the 12-month follow-up. Changes in CTS symptom severity between baseline and the 12-month follow-up were analyzed between groups using t-tests and a multiple linear regression analyses, adjusting for duration of complaints, age, gender, and symptom severity at baseline. Results: At the 12-month follow-up, 35 of 94 (37%) patients in the intervention group had surgery, compared to 38 of 87 (44%) in the care-as-usual group (χ12 = 0.78, p = 0.377). Symptom severity and functional status scores did not significantly differ between the intervention (n = 81) and care-as-usual group (n = 55) at follow-up. For patients who did not have surgery, BCTQ scores decreased significantly more from baseline to the 12-month follow-up in the intervention group (n = 53) compared to patients in the care-as-usual group (n = 25). For patients who did not have surgery, belonging to the intervention group and a higher BCTQ score at baseline were related to a greater decrease in BCTQ scores from baseline to the 12-month follow-up, as well as symptom severity and functional status. Conclusions: Mechanical traction is effective in reducing symptom severity compared to current conservative treatment options in standard care and can therefore benefit the large number of patients that prefer conservative treatment for CTS. Clinical Trial Registration: Clinical Trials NL44692.008.13. Registered 19 September 2013, https://clinicaltrials.gov/ct2/show/NCT01949493
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Affiliation(s)
- Margreet Meems
- Department of Medical and Clinical Psychology, Centre of Research on Psychology in Somatic Diseases, Tilburg University, Tilburg, Netherlands
| | - Myrthe G B M Boekhorst
- Department of Medical and Clinical Psychology, Centre of Research on Psychology in Somatic Diseases, Tilburg University, Tilburg, Netherlands
| | - Victor J M Pop
- Department of Medical and Clinical Psychology, Centre of Research on Psychology in Somatic Diseases, Tilburg University, Tilburg, Netherlands
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22
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Sensory Nerve Conduction Velocity Predicts Improvement of Hand Function with Nerve Gliding Exercise Following Carpal Tunnel Release Surgery. J Clin Med 2021; 10:jcm10184121. [PMID: 34575232 PMCID: PMC8470096 DOI: 10.3390/jcm10184121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/04/2021] [Accepted: 09/10/2021] [Indexed: 12/31/2022] Open
Abstract
This study aims to investigate the effects of nerve gliding exercise following carpal tunnel release surgery (NGE-CTRS) and the probing factors affecting the effect of NGE-CTRS on hand function. A total of 86 patients after CTRS participated. Grip strength (grip-s), pinch strength (pinch-s), Semmes-Weinstein monofilament test (SWMT), two-point discrimination (2PD), numbness, pain, and Phalen test (Phalen) were measured and compared between pre- and post-NGE-CTRS. The results showed that the combination of surgery and NGE significantly improved the postoperative grip-s, pinch-s, SWMT, 2PD, numbness, and Phalen; however, no improvement was observed in pain. Background factors that influenced the improved grip-s and pinch-s included gender and preoperative sensory nerve conduction velocity (SCV). Additionally, numbness and Phalen were not affected by age, gender, fault side, bilateral, trigger finger, dialysis, thenar eminence atrophy, motor nerve conduction velocity, SCV, the start of treatment, and occupational therapy intervention. In conclusion, the combination of surgical procedures and NGE showed a high improvement. SCV and time-to-start treatment of intervention for carpal tunnel syndrome may be useful in predicting the function after the intervention.
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23
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Wang H, Zhu Y, Wei H, Dong C. Ultrasound-guided local corticosteroid injection for carpal tunnel syndrome: A meta-analysis of randomized controlled trials. Clin Rehabil 2021; 35:1506-1517. [PMID: 34096345 DOI: 10.1177/02692155211014702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This meta-analysis aimed to compare the efficacy and safety of ultrasound-guided (US-guided) versus landmark-guided (LM-guided) local corticosteroid injection for carpal tunnel syndrome (CTS). METHODS Database including Pubmed, Embase, and Cochrane Library were searched to identify relevant randomized controlled trials (RCTs). The outcomes mainly included Boston Carpal Tunnel Questionnaire (BCTQ): Symptom Severity Scale (BCTQs), Functional Status Scale (BCTQf); and electrophysiological indexes: distal motor latency (DML), sensory distal latency (SDL), compound muscle action potential (CAMP), sensory nerve action potential amplitude (SNAP), and sensory nerve conduction velocity (SNCV). Adverse events were also recorded. RESULTS Overall, nine RCTs were finally screened out with 469 patients (596 injected hands). Pooled analysis showed that US-guided injection was more effective in BCTQs (SMD, -0.69; 95% CI, -1.08 to -0.31; P = 0.0005), BCTQf (SMD, -0.23; 95% CI, -0.39 to -0.07; P = 0.005), CAMP (MD, 0.64; 95% CI, 0.35-0.94; P < 0.0001) improvement, and a lower rate of adverse events (RR, 0.34; 95% CI, 0.22-0.52; P < 0.00001). Subgroup analysis revealed that the US-guided injection had significantly better CMAP than the LM-guided for the in-plane approach (MD, 0.69; 95% CI, 0.36-1.01; P < 0.0001) but not for the out-plane approach (MD, 0.39; 95% CI, -0.39 to 1.17; P = 0.33). CONCLUSIONS US-guided injection was superior to LM-guided injection in symptom severity, functional status, electrodiagnostic, and adverse events improvement for CTS. To some extent, the in-plane approach yields better results compared with the out-plane process under US guidance.
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Affiliation(s)
- Hongchen Wang
- Department of Orthopaedic Surgery, Beijing Daxing District Hospital of Integrative Chinese and Western Medicine, Beijing, China
| | - Yuting Zhu
- Beijing Tongzhou Integrative Medicine Hospital, Beijing, China
| | - Hongyu Wei
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Chunke Dong
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
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24
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Ultrasound-guided corticosteroid injection for patients with carpal tunnel syndrome: a systematic review and meta-analysis of randomized controlled trials. Sci Rep 2021; 11:10417. [PMID: 34001949 PMCID: PMC8128919 DOI: 10.1038/s41598-021-89898-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 04/27/2021] [Indexed: 01/11/2023] Open
Abstract
Carpal tunnel syndrome (CTS) refers to the symptoms and signs caused by the compression of the median nerve in the carpal tunnel. It can be treated by corticosteroid injection into the carpal tunnel. Two methods for injection have been employed, namely ultrasound-guided and landmark-guided injection. This systematic review and meta-analysis was conducted to compare these methods in terms of several outcomes. A search of the PubMed, Cochrane Library, and Embase databases was performed from the date of their inception to October 7, 2020 to identify randomized controlled trials (RCTs). Results for continuous variables are expressed as standardized mean differences (SMDs) with 95% confidence intervals (CIs). Analyses were performed using RevMan 5.3 software. The analysis included eight RCTs published between 2013 and 2019 with a total of 448 patients. Ultrasound-guided injection yielded more favorable results than landmark-guided injection for the Boston Carpal Tunnel Syndrome Questionnaire, Symptom Severity Scale [SMD = − 0.43, 95% CI (− 0.68, − 0.19), P = 0.0005] and Boston Carpal Tunnel Syndrome Questionnaire, Functional Status Scale [SMD = − 0.50, 95% CI (− 0.84, − 0.15), P = 0.005]. Ultrasound-guided corticosteroid injection is recommended for patients with CTS.
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25
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Knightly N, Finnegan L, Qayyum T, Kelly JL. Novel steroid infiltration technique of the carpal tunnel. BMJ Case Rep 2021; 14:e240764. [PMID: 33910798 PMCID: PMC8094330 DOI: 10.1136/bcr-2020-240764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2021] [Indexed: 11/28/2022] Open
Abstract
This report describes a novel technique of steroid infiltration of the wrist to treat symptomatic carpal tunnel syndrome. Our approach potentially reduces direct trauma to the median nerve when compared with current conventional techniques. The use of a cannula allows infiltration directly into the carpal tunnel and advancement of the blunt tip minimises the risk of sharp trauma to the median nerve and adjacent tendons. This avoids the unpleasant, shooting pain frequently experienced by patients using traditional needle infiltration. We anticipate this would be of particular benefit in reducing pain associated with the procedure.
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Affiliation(s)
- Nauar Knightly
- Plastic and Reconstructive Surgery, Galway University Hospitals, Galway, Ireland
| | - Laura Finnegan
- Plastic and Reconstructive Surgery, Galway University Hospitals, Galway, Ireland
| | - Tayyab Qayyum
- Plastic and Reconstructive Surgery, Galway University Hospitals, Galway, Ireland
| | - Jack L Kelly
- Department of Plastic Surgery, Galway University Hospitals, Galway, Ireland
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26
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Mezian K, SobotovÁ K, Kuliha M, Chang KV, CeÉ J, AngerovÁ Y, ÖzÇakar L. Ultrasound-guided perineural vs. peritendinous corticosteroid injections in carpal tunnel syndrome: a randomized controlled trial. Eur J Phys Rehabil Med 2021; 57:775-782. [PMID: 33733720 DOI: 10.23736/s1973-9087.21.06682-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Corticosteroid injections are proven to be effective in the management of carpal tunnel syndrome (CTS); however, the optimal injection site still remains unclear. AIM To compare the efficacy of perineural vs. peritendinous target sites for corticosteroid injection in CTS. DESIGN A Randomized, Single-Blind, Controlled Trial. SETTING Outpatients, tertiary care center. POPULATION Forty-six patients were equally randomized into two intervention groups as Group A (18 F and 5 M, mean age;50.0 ± 15.9 years, mean symptom duration;5.9 ± 3.3 months) and Group B (19 F, 4 M patients, mean age;54.3 ± 15.0 years, mean symptom duration;5.9 ± 4.7 months). METHODS Methylprednisolone acetate (40 mg) and 1 mL of 1% trimecaine hydrochloride was injected next to the median nerve (Group A) or among flexor tendons away from the nerve (Group B) under ultrasound (US) guidance. The visual analogue scale was used as the primary outcome measure, and the symptom severity scale and functional status scale of the Boston Carpal Tunnel Questionnaire were used as the secondary subjective outcome measures. Twopoint discrimination, grip strength, cross-sectional area, and distal motor latency were assessed as objective outcome measures. The data were collected at baseline and at 2, 6 and 12 weeks after the injection. RESULTS Both groups showed improvement in subjective and objective measures at 2 weeks following the injection - also maintained up to 12 weeks during the follow-up (p<0.05). However, no difference was observed between the two groups (p<0.05). No serious adverse effects were observed in either group. CONCLUSIONS Both intervention techniques seem to be effective and safe in the conservative treatment of CTS. CLINICAL REHABILITATION IMPACT Based on this study results, it might be noteworthy that physicians can opt for perineural or peritendinous injections without compromising the treatment efficacy and safety. Herewith, US guidance is, for sure, necessary for performing safe and accurate injections.
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Affiliation(s)
- Kamal Mezian
- Department of Rehabilitation Medicine, First Faculty of Medicine and General University Hospital in Prague, Charles University, Prague, Czech Republic -
| | - Karolína SobotovÁ
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | | | - Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei City, Taiwan. 5 Department of Neurosurgery, J. E. Purkyně University, Masaryk Hospital, Ústí nad Labem, Czech Republic
| | - Jiří CeÉ
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
| | - Yvona AngerovÁ
- Department of Rehabilitation Medicine, First Faculty of Medicine and General University Hospital in Prague, Charles University, Prague, Czech Republic
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27
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Koyama T, Sato S, Toriumi M, Watanabe T, Nimura A, Okawa A, Sugiura Y, Fujita K. A Screening Method Using Anomaly Detection on a Smartphone for Patients With Carpal Tunnel Syndrome: Diagnostic Case-Control Study. JMIR Mhealth Uhealth 2021; 9:e26320. [PMID: 33714936 PMCID: PMC8005991 DOI: 10.2196/26320] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/15/2021] [Accepted: 02/27/2021] [Indexed: 01/23/2023] Open
Abstract
Background Carpal tunnel syndrome (CTS) is a medical condition caused by compression of the median nerve in the carpal tunnel due to aging or overuse of the hand. The symptoms include numbness of the fingers and atrophy of the thenar muscle. Thenar atrophy recovers slowly postoperatively; therefore, early diagnosis and surgery are important. While physical examinations and nerve conduction studies are used to diagnose CTS, problems with the diagnostic ability and equipment, respectively, exist. Despite research on a CTS-screening app that uses a tablet and machine learning, problems with the usage rate of tablets and data collection for machine learning remain. Objective To make data collection for machine learning easier and more available, we developed a screening app for CTS using a smartphone and an anomaly detection algorithm, aiming to examine our system as a useful screening tool for CTS. Methods In total, 36 participants were recruited, comprising 36 hands with CTS and 27 hands without CTS. Participants controlled the character in our app using their thumbs. We recorded the position of the thumbs and time; generated screening models that classified CTS and non-CTS using anomaly detection and an autoencoder; and calculated the sensitivity, specificity, and area under the curve (AUC). Results Participants with and without CTS were classified with 94% sensitivity, 67% specificity, and an AUC of 0.86. When dividing the data by direction, the model with data in the same direction as the thumb opposition had the highest AUC of 0.99, 92% sensitivity, and 100% specificity. Conclusions Our app could reveal the difficulty of thumb opposition for patients with CTS and screen for CTS with high sensitivity and specificity. The app is highly accessible because of the use of smartphones and can be easily enhanced by anomaly detection.
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Affiliation(s)
- Takafumi Koyama
- Department of Orthopedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shusuke Sato
- School of Science for Open and Environmental Systems, Graduate School of Science and Technology, Keio University, Kanagawa, Japan
| | - Madoka Toriumi
- School of Science for Open and Environmental Systems, Graduate School of Science and Technology, Keio University, Kanagawa, Japan
| | - Takuro Watanabe
- School of Science for Open and Environmental Systems, Graduate School of Science and Technology, Keio University, Kanagawa, Japan
| | - Akimoto Nimura
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Okawa
- Department of Orthopedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuta Sugiura
- School of Science for Open and Environmental Systems, Graduate School of Science and Technology, Keio University, Kanagawa, Japan
| | - Koji Fujita
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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28
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DİLEK B. Romatolojik hastalıklarda tuzak nöropatileri: Konservatif tedavi. EGE TIP DERGISI 2021. [DOI: 10.19161/etd.863628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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29
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Ho TY, Chen SR, Li TY, Li CY, Lam KHS, Chen LC, Md YTW. Prognostic factors in carpal tunnel syndrome treated with 5% dextrose perineural injection: A retrospective study. Int J Med Sci 2021; 18:1960-1965. [PMID: 33850465 PMCID: PMC8040404 DOI: 10.7150/ijms.56142] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/12/2021] [Indexed: 12/31/2022] Open
Abstract
Background: Perineural injection therapy with 5% dextrose water (D5W) is a potential and innovative treatment with long-term efficacy for carpal tunnel syndrome (CTS). However, the prognostic factors of this management are lacking; hence, the aim of this retrospective study was to identify the prognostic factors of D5W perineural injection therapy for mild-to-moderate CTS. Methods: A total of 52 patients (52 wrists) diagnosed with mild-to-moderate CTS and treated with a single ultrasound-guided 5cc D5W perineural injection were retrospectively reviewed. Patient-reported injection outcomes (visual analog scale, VAS) at 6 months post-injection were categorized into two groups; (1) Good outcome, when symptom relief ≥50% compared to pre-injection and (2) Poor outcome, when symptom relief < 50% compared to pre-injection. Significant variables between groups were entered into a binary logistic regression with forward stepwise regression to determine the prognostic factors for these outcomes. Results: The treatment outcome was significantly related to body height and sensory nerve conduction velocity (SNCV) (159.1 ± 1.0 vs. 155.0 ± 1.8, p=0.04; 33.6 ± 0.8 vs. 28.3 ± 1.2, p=0.001, good vs. poor outcomes). However, only SNCV remained significantly correlated with the outcomes after conducting stepwise logistic regression (ORs: 1.201; 95% CI 1.05-1.38; p=0.01). Conclusions: SNCV was found to be a significant prognostic factor of treatment outcome for patients with mild-to-moderate CTS 6 months after a D5W perineural injection.
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Affiliation(s)
- Tsung-Yen Ho
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Road, Neihu District, Taipei, Taiwan, Republic of China.,Department of Physical Medicine and Rehabilitation, Taichung Armed Forces General Hospital, No. 348, Sec. 2, Chungshan Road, Taiping District, Taichung City, Taiwan, Republic of China
| | - Si-Ru Chen
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Road, Neihu District, Taipei, Taiwan, Republic of China
| | - Tsung-Ying Li
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Road, Neihu District, Taipei, Taiwan, Republic of China.,Integrated Pain Management Center, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Road, Neihu District, Taipei, Taiwan, Republic of China
| | - Chun-Yi Li
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Road, Neihu District, Taipei, Taiwan, Republic of China
| | - King Hei Stanley Lam
- The Hong Kong Institute of Musculoskeletal Medicine, Hong Kong.,Department of Family Medicine, The Chinese University of Hong Kong, Hong Kong.,Department of Family Medicine, The University of Hong Kong, Hong Kong
| | - Liang-Cheng Chen
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Road, Neihu District, Taipei, Taiwan, Republic of China
| | - Yung-Tsan Wu Md
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Road, Neihu District, Taipei, Taiwan, Republic of China.,Integrated Pain Management Center, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, No. 325, Sec. 2, Cheng-Kung Road, Neihu District, Taipei, Taiwan, Republic of China
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30
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Ashworth NL, Bland JDP, Chapman KM, Tardif G, Albarqouni L, Nagendran A. Local corticosteroid injection for carpal tunnel syndrome. Hippokratia 2020. [DOI: 10.1002/14651858.cd013785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Nigel L Ashworth
- Physical Medicine & Rehabilitation; University of Alberta; Edmonton Canada
| | - Jeremy D P Bland
- Electroencephalography (EEG) Department; East Kent Hospitals University NHS Trust; Canterbury UK
| | - Kristine M Chapman
- Neuromuscular Disease Unit; 8th Floor, Diamond Health Care Centre; Vancouver Canada
| | - Gaetan Tardif
- Division of Physical Medicine & Rehabilitation; University of Toronto; Toronto Canada
| | - Loai Albarqouni
- Institute for Evidence-Based Healthcare; Bond University; Gold Coast Australia
| | - Arjuna Nagendran
- Department of Clinical Neurophysiology; National Hospital for Neurology and Neurosurgery; London UK
- Department of Clinical Neurophysiology; London North West University Healthcare NHS Trust; London UK
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31
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Abstract
Background: Our study aims to identify any influence that anticoagulation and antiplatelet ("blood thinner") medications have on hand and wrist corticosteroid injection complication rates. Methods: This retrospective chart review looked at patients between the ages of 18 and 89 years who received corticosteroid injections in the hand or wrist between 2013 and 2017, noting anticoagulation and antiplatelet use, demographics, injection placement, and surgical intervention. Results: Only 152 (20.9%) of the 726 diagnoses that were treated needed eventual surgical intervention. There were 12 overall reported complications after 1473 injections (0.8%). There were 6 complications after 433 injections (1.6%) placed in patients on blood thinners and 6 complications after 1040 injections (0.6%) placed in patients not on blood thinners. Conclusions: With the complication rate of corticosteroid injections being so low, even in patients taking "blood thinners," the fear of adverse reactions should not preclude a physician from using this treatment modality to prevent surgical intervention.
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Affiliation(s)
- Ajith Malige
- St. Luke’s University Hospital, Bethlehem, PA, USA
| | - Kristofer S. Matullo
- St. Luke’s University Hospital, Bethlehem, PA, USA,Kristofer S. Matullo, Department of Orthopaedic Surgery, St. Luke’s University Hospital, 801 Ostrum Street, Bethlehem, PA 18015, USA.
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32
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Schmid AB, Fundaun J, Tampin B. Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management. Pain Rep 2020; 5:e829. [PMID: 32766466 PMCID: PMC7382548 DOI: 10.1097/pr9.0000000000000829] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 05/04/2020] [Accepted: 05/30/2020] [Indexed: 12/18/2022] Open
Abstract
Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potential mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.
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Affiliation(s)
- Annina B. Schmid
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, United Kingdom
| | - Joel Fundaun
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, United Kingdom
- High Country Physical Therapy, Laramie, WY, USA
| | - Brigitte Tampin
- Department of Physiotherapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Physiotherapy and Exercise Science, Curtin University, Western Australia, Australia
- Faculty of Business Management and Social Sciences, Hochschule Osnabrück, University of Applied Sciences, Osnabrück, Germany
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Lin CP, Chang KV, Huang YK, Wu WT, Özçakar L. Regenerative Injections Including 5% Dextrose and Platelet-Rich Plasma for the Treatment of Carpal Tunnel Syndrome: A Systematic Review and Network Meta-Analysis. Pharmaceuticals (Basel) 2020; 13:ph13030049. [PMID: 32197544 PMCID: PMC7151714 DOI: 10.3390/ph13030049] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/13/2020] [Accepted: 03/14/2020] [Indexed: 02/07/2023] Open
Abstract
This network meta-analysis aimed to integrate the available direct and indirect evidence on regenerative injections—including 5% dextrose (D5W) and platelet-rich plasma (PRP)—for the treatment of carpal tunnel syndrome (CTS). Literature reports comparing D5W and PRP injections with non-surgical managements of CTS were systematically reviewed. The main outcome was the standardized mean difference (SMD) of the symptom severity and functional status scales of the Boston Carpal Tunnel Syndrome Questionnaire at three months after injections. Ranking probabilities of the SMD of each treatment were acquired by using simulation. Ten studies with 497 patients and comparing five treatments (D5W, PRP, splinting, corticosteroid, and normal saline) were included. The results of the simulation of rank probabilities showed that D5W injection was likely to be the best treatment, followed by PRP injection, in terms of clinical effectiveness in providing symptom relief. With respect to functional improvement, splinting ranked higher than PRP and D5W injections. Lastly, corticosteroid and saline injections were consistently ranked fourth and fifth in terms of therapeutic effects on symptom severity and functional status. D5W and PRP injections are more effective than splinting and corticosteroid or saline injection for relieving the symptoms of CTS. Compared with splinting, D5W and PRP injections do not provide better functional recovery. More studies investigating the long-term effectiveness of regenerative injections in CTS are needed in the future.
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Affiliation(s)
- Chih-Peng Lin
- Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 10048, Taiwan;
| | - Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 10048, Taiwan
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei 10845, Taiwan;
- Correspondence: ; Tel.: +886-2-23717101-5309
| | - Yi-Kai Huang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu 30059, Taiwan;
| | - Wei-Ting Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei 10845, Taiwan;
| | - Levent Özçakar
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara 06100, Turkey;
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Abstract
Background: Carpal tunnel syndrome (CTS) is one of the most common compressive neuropathies and affects a large amount of individuals. We investigated the direct and indirect cost to society of operative versus nonoperative management of CTS. Methods: A Monte Carlo simulation model was used to estimate the lifetime direct and indirect costs associated with nonoperative and operative treatment of CTS, and its utility to patients. Results: Operative treatment of CTS had a lower total cost and a higher utility when compared with nonoperative treatment. Conclusions: CTS surgery is clearly a cost-effective treatment strategy that should be included in the societal perspective regarding evolving costs and savings associated with health care.
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Affiliation(s)
- Alexandra S. Gabrielli
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, PA, USA,Alexandra S. Gabrielli, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufmann Medical Building, Suite 1010, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA.
| | - Alex C. Lesiak
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, PA, USA
| | - John R. Fowler
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, PA, USA
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Abstract
Background: Corticosteroid injection into the carpal tunnel is both a diagnostic test and a therapeutic modality in the treatment of carpal tunnel syndrome. Many injection techniques are described in the literature. Improper placement of injection may result in damage to neurovascular structures in the carpal canal or decrease efficacy of the test and/or therapy. The purpose of this study is to determine if carpal tunnel injection using anatomic landmarks is reproducible and safe. A review of the senior author's injection technique is presented. Methods: Over 8 years, there were 756 attempted placements of a 25-gauge needle into the carpal tunnel in a simulated carpal tunnel injection prior to open carpal tunnel release. The needle was inserted at the wrist crease, just ulnar to palmaris longus. Open carpal tunnel release was subsequently performed, and position of the needle was recorded. Results: In 572 patients (75.7%), the needle was found to be in the carpal tunnel without penetration of contents. The needle was in the carpal tunnel but piercing the median nerve in 66 attempts (8.7%). The carpal tunnel was missed in 118 attempts (15.6%). Conclusions: This is the largest study looking at accuracy of carpal tunnel injection using anatomic landmarks. Our injection accuracy (75.7%) is less than reported in previous studies, which note 82% to 100% accuracy using the same injection technique. This may indicate that carpal tunnel injection is less reliable than previously thought. Safety of carpal tunnel injection remains an important concern. The median nerve was penetrated in 8.7% of attempts.
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Affiliation(s)
| | - Brendan J. MacKay
- Texas Tech University Health Sciences
Center, Lubbock, USA
- Brendan J. MacKay, Department of Orthopaedic
Surgery, School of Medicine, Texas Tech University Health Sciences Center, 3601
4th Street, Lubbock, TX 79430, USA.
| | - Steven J. Seiler
- Orthopaedic & Spine Center of the
Rockies, Fort Collins, CO, USA
| | - Michael T. Fry
- Texas Tech University Health Sciences
Center, Lubbock, USA
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Platelet-rich plasma in treatment of patients with idiopathic carpal tunnel syndrome. Clin Rheumatol 2019; 38:3643-3654. [DOI: 10.1007/s10067-019-04719-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/21/2019] [Accepted: 07/30/2019] [Indexed: 12/31/2022]
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Yao Y, Grandy E, Jenkins L, Hou J, Evans PJ, Seitz WH, Li ZM. Changes of median nerve conduction, cross-sectional area and mobility by radioulnar wrist compression intervention in patients with carpal tunnel syndrome. J Orthop Translat 2019; 18:13-19. [PMID: 31508303 PMCID: PMC6718919 DOI: 10.1016/j.jot.2019.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 01/16/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Owing to the compressive nature of the neuropathy, patients with carpal tunnel syndrome (CTS) have prolonged distal motor latency (DML), sensory nerve latency (SNL), median nerve swelling and restricted median nerve mobility. The purpose of this study was to noninvasively augment carpal tunnel space using radioulnar wrist compression (RWC) and evaluate its effects on median nerve pathological properties in patients with CTS. It was hypothesized that the RWC intervention would reduce the median nerve DML, SNL and cross-sectional area (CSA) and enhance longitudinal median nerve mobility in patients. with CTS. METHODS Eleven patients diagnosed with CTS participated in this study. A portable RWC intervention splint was developed to apply 10 N of compressive force across the wrist. Three daily sessions of RWC were performed over 4 weeks of intervention (15 min per session, 45 min per day, 7 days per week). Each 15-min session consisted of three 5-min blocks of RWC, with a 1-min rest in between consecutive blocks. Patients were evaluated at Week 0 (baseline), Week 2 (mid-intervention) and Week 4 (end of intervention). DML and SNL of the median nerve were evaluated using established nerve conduction study techniques. Median nerve CSA at the distal wrist crease was obtained by ultrasound imaging. Median nerve motion associated with finger flexion/extension was captured by dynamic ultrasound imaging and quantified using a speckle cross-correlation algorithm. Finger flexion/extension was recorded using an electrogoniometer. The slope of the regressed linear equation of median nerve displacement as a function of finger flexion angle was used to quantify nerve mobility. RESULTS Patients with CTS showed significantly decreased DML (p = 0.048) and median nerve CSA (p < 0.001) and increased nerve mobility (p < 0.001) at mid-intervention compared to baseline. However, DML, CSA and mobility of the median nerve did not differ significantly between Weeks 2 and 4 (p = 0.574, 1.00 and 0.139, respectively). Median nerve SNL was not significantly affected throughout the 4-week intervention (p = 0.330 for Week 0 vs. 2; p = 1.00 for Week 2 vs. 4). CONCLUSION This study revealed that RWC intervention with 10-N force applied to the wrist in the radioulnar direction could restore impaired neurophysiological and biomechanical functions of the median nerve. The beneficial effects of RWC intervention for the median nerve were in evidence after a relatively short period of two weeks. These functional improvements could be explained by intermittent decompression of the median nerve via RWC-induced augmentation of the carpal arch. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE Biomechanically manipulating the carpal tunnel by RWC decompresses the median nerve and has the potential to become an alternative treatment for CTS.
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Affiliation(s)
- Yifei Yao
- Hand Research Laboratory, Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
| | - Emily Grandy
- Hand Research Laboratory, Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
| | - Lenicia Jenkins
- Hand Research Laboratory, Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
| | - Juliet Hou
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Peter J. Evans
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - William H. Seitz
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Zong-Ming Li
- Hand Research Laboratory, Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
- Department of Physical Medicine and Rehabilitation, Cleveland Clinic, Cleveland, OH, USA
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Abstract
BACKGROUND Recurrent carpal tunnel syndrome is often associated with perineural scarring around the median nerve. Surgical options include relatively invasive procedures, such as fat pad grafting, ligament reconstruction, muscle transfer, and nerve wraps. All have limited success because of the possibility of repeated recurrent scarring postoperatively. METHODS We discuss a technique involving injection with external hydroneurolysis of the median nerve under ultrasound guidance for recurrent carpal tunnel. Injection enables a gentler dissection of the surrounding tissues compared with open external neurolysis, with less chance of recurrent scarring. This technique is a unique alternative to repeat operative intervention in recurrent carpal tunnel, as well as a prelude to repeat open decompression and salvage procedures. RESULTS Ultrasound-guided injection with external hydroneurolysis of the median nerve is a safer, more limited procedure compared with repeat open surgery, usually performed in an office setting. This procedure limits risk, anesthesia, and operating/recovery room expenses, offering relief in 70% to 80% of cases. Furthermore, in the 20% to 30% of patients with inadequate relief, surgery remains a viable option. US provides important information on the anatomy of the median nerve and carpal canal and can rule out covert pathology. CONCLUSIONS We offer an alternative treatment for recurrent carpal tunnel syndrome, a difficult problem for which many surgeons recommend nonoperative treatment. US provides objective data concerning residual nerve compression and allows for dynamic assessment. Theoretically, this also offers a viable solution for surgeons and their patients with recurrent carpal tunnel syndrome before being pressed to consider repeat open surgery.
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Wiberg A, Ng M, Schmid AB, Smillie RW, Baskozos G, Holmes MV, Künnapuu K, Mägi R, Bennett DL, Furniss D. A genome-wide association analysis identifies 16 novel susceptibility loci for carpal tunnel syndrome. Nat Commun 2019; 10:1030. [PMID: 30833571 PMCID: PMC6399342 DOI: 10.1038/s41467-019-08993-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 02/13/2019] [Indexed: 01/07/2023] Open
Abstract
Carpal tunnel syndrome (CTS) is a common and disabling condition of the hand caused by entrapment of the median nerve at the level of the wrist. It is the commonest entrapment neuropathy, with estimates of prevalence ranging between 5-10%. Here, we undertake a genome-wide association study (GWAS) of an entrapment neuropathy, using 12,312 CTS cases and 389,344 controls identified in UK Biobank. We discover 16 susceptibility loci for CTS with p < 5 × 10-8. We identify likely causal genes in the pathogenesis of CTS, including ADAMTS17, ADAMTS10 and EFEMP1, and using RNA sequencing demonstrate expression of these genes in surgically resected tenosynovium from CTS patients. We perform Mendelian randomisation and demonstrate a causal relationship between short stature and higher risk of CTS. We suggest that variants within genes implicated in growth and extracellular matrix architecture contribute to the genetic predisposition to CTS by altering the environment through which the median nerve transits.
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Affiliation(s)
- Akira Wiberg
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Science, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK.,Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK.,Department of Plastic and Reconstructive Surgery, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Michael Ng
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Science, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK
| | - Annina B Schmid
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Robert W Smillie
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Science, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK
| | - Georgios Baskozos
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Michael V Holmes
- Medical Research Council Population Health Research Unit at the University of Oxford, Oxford, OX3 7LF, UK.,Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF, UK
| | - K Künnapuu
- Institute of Technology, University of Tartu, Nooruse 1, 50411, Tartu, Estonia
| | - R Mägi
- Estonian Genome Center, Institute of Genomics, University of Tartu, Riia 23 B, 51010, Tartu, Estonia
| | - David L Bennett
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
| | - Dominic Furniss
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Science, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK. .,Department of Plastic and Reconstructive Surgery, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
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Karimzadeh A, Bagheri S, Raeissadat SA, Bagheri S, Rayegani SM, Rahimi-Dehgolan S, Safdari F, Abrishamkarzadeh H, Shirzad H. The comparison of the effectiveness between different doses of local methylprednisolone injection versus triamcinolone in Carpal Tunnel Syndrome: a double-blind clinical trial. J Pain Res 2019; 12:579-584. [PMID: 30787634 PMCID: PMC6368124 DOI: 10.2147/jpr.s190652] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Purpose Local corticosteroid injection is one of the most prevalent methods in treating carpal tunnel syndrome (CTS). However, the most efficient substance and its appropriate dosage remain controversial. In the present double-blind randomized controlled trial, the efficacy and safety of local injection of two corticosteroids (triamcinolone and methylprednisolone) were compared at two different dosages, 20 and 40 mg. Patients and methods We consecutively included 80 patients with mild or moderate CTS and randomly assigned them to four groups: 20 or 40 mg triamcinolone (T20 or T40) and 20 or 40 mg methylprednisolone (M20 or M40) groups; each patient received a single injection of steroid using conventional approach. The four groups were relatively comparable and did not show any significant difference initially in their baseline measurements including pain intensity measured using VAS, pain-free grip strength (PFGS), nerve conduction study (NCS), and two parts of Boston Carpal Tunnel Syndrome Questionnaire: symptom severity scale (SSS) and functional status scale (FSS); the latter was our primary outcome measure. Three months after injection, they were reassessed to evaluate the clinical and electrodiagnostic changes. Results Almost all NCS parameters, VAS, and PFGS significantly improved after treatment in all the groups (P<0.05). Compound motor action potential amplitude significantly improved only in T40 group (P=0.032), while there was no significant improvement in other groups. Furthermore, SSS remarkably decreased in all the four groups, without any significant difference between the groups (P=0.87). A similar significant decrease was found in FSS, with a higher improvement in T40 group (P=0.009). There was no significant difference between the four groups in other variables after treatment. Conclusion Based on the current data, the efficacy and safety of local injection of triamcinolone and methylprednisolone at doses of 20 and 40 mg were associated with a significant improvement in pain, functional status, and strength. Although, there was no remarkable superiority, 40 mg injection, especially for triamcinolone, yielded better NCS results and functional status
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Affiliation(s)
- Afshin Karimzadeh
- Department of Physical Medicine and Rehabilitation, Clinical Research Development Center of Imam-Hossein Educational Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahriar Bagheri
- Department of Orthopedic Surgery, Bone, Joint and Related Tissue Research Center, Akhtar Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Ahmad Raeissadat
- Clinical Development Research Center of Shahid Modarres Hospital, Physical Medicine and Rehabilitation Department and Research Center, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran,
| | - Shahab Bagheri
- Physical Medicine and Rehabilitation Department and Research Center, Shohada-e-Tajrish Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Mansoor Rayegani
- Physical Medicine and Rehabilitation Department and Research Center, Shohada-e-Tajrish Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahram Rahimi-Dehgolan
- Department of Physical Medicine and Rehabilitation, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Farshad Safdari
- Department of Orthopedic Surgery, Bone, Joint and Related Tissue Research Center, Akhtar Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hashem Abrishamkarzadeh
- Department of Orthopedic Surgery, Bone, Joint and Related Tissue Research Center, Akhtar Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hadi Shirzad
- Department of Medical Genetics, Tarbiat Modares University, Tehran, Iran
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Choi G, Wieland LS, Lee H, Sim H, Lee MS, Shin B. Acupuncture and related interventions for the treatment of symptoms associated with carpal tunnel syndrome. Cochrane Database Syst Rev 2018; 12:CD011215. [PMID: 30521680 PMCID: PMC6361189 DOI: 10.1002/14651858.cd011215.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Carpal tunnel syndrome (CTS) is a compressive neuropathic disorder at the level of the wrist. Acupuncture and other methods that stimulate acupuncture points, such as electroacupuncture, auricular acupuncture, laser acupuncture, moxibustion, and acupressure, are used in treating CTS. Acupuncture has been recommended as a potentially useful treatment for CTS, but its effectiveness remains uncertain. We used Cochrane methodology to assess the evidence from randomised and quasi-randomised trials of acupuncture for symptoms in people with CTS. OBJECTIVES To assess the benefits and harms of acupuncture and acupuncture-related interventions compared to sham or active treatments for the management of pain and other symptoms of CTS in adults. SEARCH METHODS On 13 November 2017, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, AMED, CINAHL Plus, DARE, HTA, and NHS EED. In addition, we searched six Korean medical databases, and three Chinese medical databases from inception to 30 April 2018. We also searched clinical trials registries for ongoing trials. SELECTION CRITERIA We included randomised and quasi-randomised trials examining the effects of acupuncture and related interventions on the symptoms of CTS in adults. Eligible studies specified diagnostic criteria for CTS. We included outcomes measured at least three weeks after randomisation. The included studies compared acupuncture and related interventions to placebo/sham treatments, or to active interventions, such as steroid nerve blocks, oral steroid, splints, non-steroidal anti-inflammatory drugs (NSAIDs), surgery and physical therapy. DATA COLLECTION AND ANALYSIS The review authors followed standard Cochrane methods. MAIN RESULTS We included 12 studies with 869 participants. Ten studies reported the primary outcome of overall clinical improvement at short-term follow-up (3 months or less) after randomisation. Most studies could not be combined in a meta-analysis due to heterogeneity, and all had an unclear or high overall risk of bias.Seven studies provided information on adverse events. Non-serious adverse events included skin bruising with electroacupuncture and local pain after needle insertion. No serious adverse events were reported.One study (N = 41) comparing acupuncture to sham/placebo reported change on the Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (SSS) at three months after treatment (mean difference (MD) -0.23, 95% confidence interval (CI) -0.79 to 0.33) and the BCTQ Functional Status Scale (FSS) (MD -0.03, 95% CI -0.69 to 0.63), with no clear difference between interventions; the evidence was of low certainty. The only dropout was due to painful acupuncture. Another study of acupuncture versus placebo/sham acupuncture (N = 111) provided no usable data.Two studies assessed laser acupuncture versus sham laser acupuncture. One study (N = 60), which was at low risk of bias, provided low-certainty evidence of a better Global Symptom Scale (GSS) score with active treatment at four weeks after treatment (MD 7.46, 95% CI 4.71 to 10.22; range of possible GSS scores is 0 to 50) and a higher response rate (risk ratio (RR) 1.59, 95% CI 1.14 to 2.22). No serious adverse events were reported in either group. The other study (N = 25) did not assess overall symptom improvement.One trial (N = 77) of conventional acupuncture versus oral corticosteroids provided very low-certainty evidence of greater improvement in GSS score (scale 0 to 50) at 13 months after treatment with acupuncture (MD 8.25, 95% CI 4.12 to 12.38) and a higher responder rate (RR 1.73, 95% CI 1.22 to 2.45). Change in GSS at two weeks or four weeks after treatment showed no clear difference between groups. Adverse events occurred in 18% of the oral corticosteroid group and 5% of the acupuncture group (RR 0.29, 95% CI 0.06 to 1.32). One study comparing electroacupuncture and oral corticosteroids reported a clinically insignificant difference in change in BCTQ score at four weeks after treatment (MD -0.30, 95% CI -0.71 to 0.10; N = 52).Combined data from two studies comparing the responder rate with acupuncture versus vitamin B12, produced a RR of 1.16 (95% CI 0.99 to 1.36; N = 100, very low-certainty evidence). No serious adverse events occurred in either group.One study of conventional acupuncture versus ibuprofen in which all participants wore night splints found very low-certainty evidence of a lower symptom score on the SSS of the BCTQ with acupuncture (MD -5.80, 95% CI -7.95 to -3.65; N = 50) at one month after treatment. Five people had adverse events with ibuprofen and none with acupuncture.One study of electroacupuncture versus night splints found no clear difference between the groups on the SSS of the BCTQ (MD 0.14, 95% CI -0.15 to 0.43; N = 60; very low-certainty evidence). Six people had adverse events with electroacupuncture and none with splints. One study of electroacupuncture plus night splints versus night splints alone presented no difference between the groups on the SSS of the BCTQ at 17 weeks (MD -0.16, 95% CI -0.36 to 0.04; N = 181, low-certainty evidence). No serious adverse events occurred in either group.One study comparing acupuncture plus NSAIDs and vitamins versus NSAIDs and vitamins alone showed no clear difference on the BCTQ SSS at four weeks (MD -0.20, 95% CI -0.86 to 0.46; very low-certainty evidence). There was no reporting on adverse events. AUTHORS' CONCLUSIONS Acupuncture and laser acupuncture may have little or no effect in the short term on symptoms of CTS in comparison with placebo or sham acupuncture. It is uncertain whether acupuncture and related interventions are more or less effective in relieving symptoms of CTS than corticosteroid nerve blocks, oral corticosteroids, vitamin B12, ibuprofen, splints, or when added to NSAIDs plus vitamins, as the certainty of any conclusions from the evidence is low or very low and most evidence is short term. The included studies covered diverse interventions, had diverse designs, limited ethnic diversity, and clinical heterogeneity. High-quality randomised controlled trials (RCTs) are necessary to rigorously assess the effects of acupuncture and related interventions upon symptoms of CTS. Based on moderate to very-low certainty evidence, acupuncture was associated with no serious adverse events, or reported discomfort, pain, local paraesthesia and temporary skin bruises, but not all studies provided adverse event data.
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Affiliation(s)
- Gwang‐Ho Choi
- Pusan National UniversitySchool of Korean MedicineBeom‐eu, MeulgeumYangsanKorea, South626‐870
| | - L Susan Wieland
- University of Maryland School of MedicineCenter for Integrative Medicine520 W. Lombard StreetBaltimoreMarylandUSA21201
| | - Hyangsook Lee
- Kyung Hee UniversityAcupuncture and Meridian Science Research Centre, College of Korean MedicineKyungheedaero 26Dongdaemun‐guSeoulKorea, South130‐701
| | - Hoseob Sim
- Pusan National UniversitySchool of Korean MedicineBeom‐eu, MeulgeumYangsanKorea, South626‐870
| | - Myeong Soo Lee
- Korea Institute of Oriental MedicineClinical Medicine Division461‐24 Jeonmin‐dong, Yuseong‐guDaejeonKorea, South34054
| | - Byung‐Cheul Shin
- School of Korean Medicine, Pusan National UniversityDepartment of Korean Rehabilitation MedicineBeom‐eu, MeulgeumYangsanKyungnamKorea, South626‐870
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Petrover D, Hakime A, Silvera J, Richette P, Nizard R. Ultrasound-Guided Surgery for Carpal Tunnel Syndrome: A New Interventional Procedure. Semin Intervent Radiol 2018; 35:248-254. [PMID: 30402007 DOI: 10.1055/s-0038-1673360] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Carpal tunnel syndrome (CTS) may be treated surgically if medical treatment fails. The classical approach involves release of the flexor retinaculum by endoscopic or open surgery. Meta-analyses have shown that the risk of nerve injury may be higher with endoscopic treatment. The recent contribution of ultrasound to the diagnosis and therapeutic management of CTS opens new perspectives. Ultrasound-guided carpal tunnel release via a minimally invasive approach enables the whole operation to be performed as a percutaneous radiological procedure. The advantages are a smaller incision compared with classical techniques; great safety during the procedure by visualization of anatomic structures, particularly variations in the median nerve; and realization of the procedure under local anesthesia. These advantages lead to a reduction in postsurgical sequelae and more rapid resumption of daily activities and work. Dressings are removed by the third day postsurgery. Recent studies seem to confirm the medical, economic, and aesthetic benefits of this new approach.
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Affiliation(s)
- David Petrover
- Centre Imagerie Medicale Bachaumont Paris Centre (IMPC Bachaumont-Blomet Ramsay GDS), Paris, France
| | - Antoine Hakime
- Centre Imagerie Medicale Bachaumont Paris Centre (IMPC Bachaumont-Blomet Ramsay GDS), Paris, France
| | - Jonathan Silvera
- Centre Imagerie Medicale Bachaumont Paris Centre (IMPC Bachaumont-Blomet Ramsay GDS), Paris, France
| | - Pascal Richette
- Service de Rhumatologie, Hôpital Lariboisière, AP-HP, Paris, France
| | - Rémy Nizard
- Service de Chirurgie Orthopédique, Hôpital Lariboisière, AP-HP, Paris, France
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Chesterton LS, Blagojevic-Bucknall M, Burton C, Dziedzic KS, Davenport G, Jowett SM, Myers HL, Oppong R, Rathod-Mistry T, van der Windt DA, Hay EM, Roddy E. The clinical and cost-effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome (INSTINCTS trial): an open-label, parallel group, randomised controlled trial. Lancet 2018; 392:1423-1433. [PMID: 30343858 PMCID: PMC6196880 DOI: 10.1016/s0140-6736(18)31572-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 06/27/2018] [Accepted: 07/03/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND To our knowledge, the comparative effectiveness of commonly used conservative treatments for carpal tunnel syndrome has not been evaluated previously in primary care. We aimed to compare the clinical and cost-effectiveness of night splints with a corticosteroid injection with regards to reducing symptoms and improving hand function in patients with mild or moderate carpal tunnel syndrome. METHODS We did this randomised, open-label, pragmatic trial in adults (≥18 years) with mild or moderate carpal tunnel syndrome recruited from 25 primary and community musculoskeletal clinics and services. Patients with a new episode of idiopathic mild or moderate carpal tunnel syndrome of at least 6 weeks' duration were eligible. We randomly assigned (1:1) patients (permutated blocks of two and four by site) with an online web or third party telephone service to receive either a single injection of 20 mg methylprednisolone acetate (from 40 mg/mL) or a night-resting splint to be worn for 6 weeks. Patients and clinicians could not be masked to the intervention. The primary outcome was the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ) at 6 weeks. We used intention-to-treat analysis, with multiple imputation for missing data, which was concealed to treatment group allocation. The trial is registered with the European Clinical Trials Database, number 2013-001435-48, and ClinicalTrial.gov, number NCT02038452. FINDINGS Between April 17, 2014, and Dec 31, 2016, 234 participants were randomly assigned (118 to the night splint group and 116 to the corticosteroid injection group), of whom 212 (91%) completed the BCTQ at 6 weeks. The BCTQ score was significantly better at 6 weeks in the corticosteroid injection group (mean 2·02 [SD 0·81]) than the night splint group (2·29 [0·75]; adjusted mean difference -0·32; 95% CI -0·48 to -0·16; p=0·0001). No adverse events were reported. INTERPRETATION A single corticosteroid injection shows superior clinical effectiveness at 6 weeks compared with night-resting splints, making it the treatment of choice for rapid symptom response in mild or moderate carpal tunnel syndrome presenting in primary care. FUNDING Arthritis Research UK.
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Affiliation(s)
- Linda S Chesterton
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Milica Blagojevic-Bucknall
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Claire Burton
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Krysia S Dziedzic
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Graham Davenport
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Sue M Jowett
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK; Health Economics Unit, Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - Helen L Myers
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK; Keele Clinical Trials Unit, Keele University, Keele, UK
| | - Raymond Oppong
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK; Health Economics Unit, Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - Trishna Rathod-Mistry
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Danielle A van der Windt
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Elaine M Hay
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK; Haywood Academic Rheumatology Centre, Haywood Hospital, Staffordshire and Stoke-on-Trent Partnership NHS Trust, Stoke-on-Trent, UK
| | - Edward Roddy
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK; Haywood Academic Rheumatology Centre, Haywood Hospital, Staffordshire and Stoke-on-Trent Partnership NHS Trust, Stoke-on-Trent, UK.
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Burton CL, Chen Y, Chesterton LS, van der Windt DA. Trends in the prevalence, incidence and surgical management of carpal tunnel syndrome between 1993 and 2013: an observational analysis of UK primary care records. BMJ Open 2018; 8:e020166. [PMID: 29921681 PMCID: PMC6020969 DOI: 10.1136/bmjopen-2017-020166] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 04/24/2018] [Accepted: 05/14/2018] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES To describe the prevalence, incidence and surgical management of carpal tunnel syndrome (CTS), between 1993 and 2013, as recorded in the Clinical Practice Research Datalink (CPRD). DESIGN We completed a series of cross-sectional epidemiological analyses to observe trends over time. SETTING Primary care data collected between 1993 and 2013, stored in the CPRD. POPULATION Individuals aged ≥18 years were selected. Prevalent and incident episodes of CTS and episodes of surgical intervention were identified using a list of preidentified Read codes. ANALYSIS We defined incident episodes as those with no preceding diagnostic code for CTS in the past 2 years of data. Episodes of surgery were expressed as a percentage of the prevalent population during the same calendar year. Joinpoint regression was used to determine significant changes in the underlying trend. RESULTS The prevalence of CTS increased over the study period, with a particular incline between 2000 and 2004 (annual percentage change 7.81). The female-to-male prevalence ratio reduced over time from 2.74 in 1993 to 1.93 in 2013. The median age of females and males with CTS were noted to increase from 49 and 53 years, respectively in 1993 to 54 and 59 years, respectively in 2013. Incidence was also noted to increase over time. After an initial increase between 1993 and 2007, the percentage of prevalent patients with a coded surgical episode began to decrease after 2007 to 27.41% in 2013 (annual percentage change -1.7). CONCLUSION This study has demonstrated that the prevalence and incidence of CTS increased over the study period between 1993 and 2013. Rates of surgery for CTS also increased over the study period; however after 2007, the per cent of patients receiving surgery showed a statistically significant decline back to the rate seen in 2004.
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Affiliation(s)
- Claire L Burton
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, UK
| | - Ying Chen
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, UK
| | - Linda S Chesterton
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, UK
| | - Danielle A van der Windt
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, UK
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Loizides A, Gruber L, Peer S, Plaikner M, Gruber H. [Ultrasound-guided interventions on the peripheral nervous system]. Radiologe 2018; 57:166-175. [PMID: 28054138 DOI: 10.1007/s00117-016-0203-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
CLINICAL/METHODICAL ISSUE Up to the advent of high-resolution ultrasound, interventions on the peripheral nervous system, including local anesthesia and pain treatment were performed without visual guidance, which in some cases led to treatment failure or local tissue and nerve damage. METHODICAL INNOVATIONS Progress in the field of ultrasound has enabled the functional visualization, anesthesia and anti-inflammatory or neurolytic treatment of many peripheral nerves, such as the brachial plexus, nerves of the upper and lower extremities and various nerves of the trunk. Contrast medium-guided biopsies have also become feasible. ACHIEVEMENTS This article discusses the general prerequisites for such interventions and details the visualization and the interventional algorithms for interventions on the brachial plexus, on large nerves often affected by compression neuropathies, such as the median, ulnar, sciatic and femoral nerves and small nerves, such as the lateral cutaneous nerves of the thigh. Furthermore, contrast medium-aided biopsies of intraneural and perineural masses are discussed. Finally, the treatment of stump neuromas via phenol instillation is described. PRACTICAL RECOMMENDATIONS Innovations in high-resolution ultrasound allow the reliable and safe diagnosis and treatment of various pathologies of the peripheral nervous system with few side effects. Compared to older methods, which did not use visual guidance ultrasound provides higher success rates and lower adverse event rates in many instances.
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Affiliation(s)
- A Loizides
- Department Radiologie, Medizinische Universität Innsbruck, 6020, Innsbruck, Österreich.
| | - L Gruber
- Department Radiologie, Medizinische Universität Innsbruck, 6020, Innsbruck, Österreich
| | - S Peer
- CTI GesmbH und Roentgeninstitut B7, 6020, Innsbruck, Österreich
| | - M Plaikner
- Department Radiologie, Medizinische Universität Innsbruck, 6020, Innsbruck, Österreich
| | - H Gruber
- Department Radiologie, Medizinische Universität Innsbruck, 6020, Innsbruck, Österreich
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Sonoo M, Menkes DL, Bland JD, Burke D. Nerve conduction studies and EMG in carpal tunnel syndrome: Do they add value? Clin Neurophysiol Pract 2018; 3:78-88. [PMID: 30215013 PMCID: PMC6133914 DOI: 10.1016/j.cnp.2018.02.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 01/28/2018] [Accepted: 02/03/2018] [Indexed: 12/31/2022] Open
Abstract
This paper summarises the views of four experts on the place of neurophysiological testing (EDX) in patients presenting with possible carpal tunnel syndrome, in guiding their treatment, and in reevaluations. This is not meant to be a position paper or a literature review, and heterogeneous viewpoints are presented. Nerve conduction studies should be performed in patients presenting with possible carpal tunnel syndrome to assist diagnosis, and may need to be repeated at intervals in those managed conservatively. There is evidence that local corticosteroid injection is safe and effective for many patients, thereby avoiding or deferring surgical decompression. All patients should undergo EDX studies before any invasive procedure for CTS (injection or surgery). Needle EMG studies are not obligatory, but may be needed in those with severe disease and those in whom an alternate or concomitant diagnosis is suspected.
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Affiliation(s)
- Masahiro Sonoo
- Department of Neurology, Teikyo University School of Medicine, Kaga 2-11-1, Itabashi-ku, Tokyo 1738605, Japan
| | - Daniel L. Menkes
- Department of Neurology, Beaumont Health, Beaumont Neuroscience Building, Royal Oak, MI 48073, United States
| | - Jeremy D.P. Bland
- East Kent Hospitals University NHS Foundation Trust, Ethelbert Road, Canterbury, Kent, UK
| | - David Burke
- Department of Neurology, Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia
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Guo XY, Xiong MX, Lu M, Cheng XQ, Wu YY, Chen SY, Chen K, Zhou QD, Wang L, Tan L, Quan JR, He FD, Chen Q. Ultrasound-guided needle release of the transverse carpal ligament with and without corticosteroid injection for the treatment of carpal tunnel syndrome. J Orthop Surg Res 2018; 13:69. [PMID: 29615088 PMCID: PMC5883285 DOI: 10.1186/s13018-018-0771-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/14/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND To compare the clinical effectiveness of ultrasound-guided needle release of the transverse carpal ligament (TCL) with and without corticosteroid injection in carpal tunnel syndrome (CTS). METHODS From June 2016 to June 2017, 49 CTS patients (50 wrists) were included in this study. Twenty-five wrists were treated with ultrasound-guided needle release of the TCL plus corticosteroid injection (group A), and 25 wrists were treated with single ultrasound-guided needle release of the TCL (group B). The following parameters were assessed and compared including postprocedure results according to relief of symptoms, ultrasound parameters (cross-sectional area of the median nerve at the levels of pisiform, flattening ratio of median nerve at the levels of the hamate bone, and the thicknesses of TCL on the cross-section at the level of the hamate bone), and electrophysiological parameters (distal motor latency and sensory conduction velocity). RESULTS Group A had higher overall excellent and good rate 3 months after the procedure than group B (84 vs 52%, P < 0.05). There were significant differences regarding the above ultrasonic and electrophysiological parameters between the baseline and postprocedure values in both groups (all P < 0.05). There were significant differences regarding the postprocedure values of above ultrasonic and electrophysiological parameters between the two groups (all P < 0.05). No complications such as infection or tendon rupture were noted. No procedures were converted to the open release. CONCLUSIONS Both techniques are effective in treating CTS. Ultrasound-guided needle release of the TCL with corticosteroid injection had better treatment benefits than single ultrasound-guided needle release of the TCL in treating CTS.
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Affiliation(s)
- Xuan-Yan Guo
- Ultrasonic Department, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 32, West Section 2, Yihuan Road, Qingyang District, Chengdu, 610072, People's Republic of China
| | - Mao-Xiang Xiong
- Psychiatry Department, Chengdu Mental Health Center, The Fourth People's Hospital of Chengdu, Chengdu, 610036, People's Republic of China
| | - Man Lu
- Ultrasonic Department, Sichuan Cancer Hospital Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610041, People's Republic of China
| | - Xue-Qing Cheng
- Ultrasonic Department, Sichuan Cancer Hospital Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610041, People's Republic of China
| | - Yan-Yan Wu
- Ultrasonic Department, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 32, West Section 2, Yihuan Road, Qingyang District, Chengdu, 610072, People's Republic of China
| | - Shi-Yin Chen
- Department of Chinese medicine orthopaedics, Sichuan Academy of Medical Sciences & Sichuan Provincal People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, People's Republic of China
| | - Kai Chen
- Ultrasonic Department, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 32, West Section 2, Yihuan Road, Qingyang District, Chengdu, 610072, People's Republic of China
| | - Qiao-Dan Zhou
- Ultrasonic Department, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 32, West Section 2, Yihuan Road, Qingyang District, Chengdu, 610072, People's Republic of China
| | - Lei Wang
- Ultrasonic Department, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 32, West Section 2, Yihuan Road, Qingyang District, Chengdu, 610072, People's Republic of China
| | - Li Tan
- Ultrasonic Department, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 32, West Section 2, Yihuan Road, Qingyang District, Chengdu, 610072, People's Republic of China
| | - Jie-Rong Quan
- Ultrasonic Department, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 32, West Section 2, Yihuan Road, Qingyang District, Chengdu, 610072, People's Republic of China
| | - Fan-Ding He
- Ultrasonic Department, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 32, West Section 2, Yihuan Road, Qingyang District, Chengdu, 610072, People's Republic of China.
| | - Qin Chen
- Ultrasonic Department, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 32, West Section 2, Yihuan Road, Qingyang District, Chengdu, 610072, People's Republic of China.
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Chung SY, Kwak JM, Kang S, Son SH, Kim JD, Yoon JS. Predictive Variables for Sonographically Guided Corticosteroid Injection in Mild-to-Moderate Carpal Tunnel Syndrome. Ann Rehabil Med 2018; 42:213-221. [PMID: 29765874 PMCID: PMC5940597 DOI: 10.5535/arm.2018.42.2.213] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/01/2017] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To assess the predictive variables after sonographically guided corticosteroid injection in carpal tunnel syndrome. METHODS A prospective, observational study was carried out on 25 wrists of 20 consecutive patients with carpal tunnel syndrome, confirmed by the American Association of Neuromuscular and Electrodiagnostic Medicine criteria, which includes clinical history, symptoms, and evidence of slowing of distal median nerve conduction. Visual analogue scale (VAS) and Boston Carpal Tunnel Questionnaire (BCTQ) were asked to the patients before and 4 weeks after the procedure. On a basis of VAS difference before and after the procedure, we divided the patients into two groups: more than 50% of VAS improving (good response group) and less than 50% of VAS improving (poor response group). Also, nerve conduction studies and ultrasound evaluations were performed prior to sonographically guided corticosteroid injection and at 4 weeks after the procedure. The cross-sectional area (CSA) of median nerve at maximal swelling point around wrist was measured by manual tracing using ultrasonography. With assessments mentioned above, we tried to assess predictive variables for prognosis after sonographically guided corticosteroid injection in carpal tunnel syndrome. RESULTS The CSA of median nerve at wrist measured before the procedure was significantly larger in good response group than in poor response group. Furthermore, the CSA of median nerve at wrist, symptom severity scale of BCTQ, motor/sensory latency and sensory amplitude were correlated with VAS improving. CONCLUSION The CSA of median nerve at wrist is the strongest predictive value for sonographically guided corticosteroid injection in mild-to-moderate carpal tunnel syndrome.
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Affiliation(s)
- Seong Yun Chung
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
| | - Jung Min Kwak
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
| | - Seok Kang
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
| | - Seong-Ho Son
- Department of Radio Technology Research, Electronics and Telecommunications Research Institute, Daejeon, Korea
| | - Jae Do Kim
- Department of Physical Medicine and Rehabilitation, Graduate School of Korea University, Seoul, Korea
| | - Joon Shik Yoon
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Korea
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Dehghan F, Haghighat S, Ramezanian H, Karami M, Rezaei MR. Ultrasonography Predictive Factors of Response to Local Steroid Injection in Patients with Carpal Tunnel Syndrome. Adv Biomed Res 2018. [PMID: 29531920 PMCID: PMC5841001 DOI: 10.4103/2277-9175.225591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background: The aim of this study is to determine the predictive value of ultrasonography for results of local steroid injection in patients with carpal tunnel syndrome (CTS). Materials and Methods: This prospective cohort study was conducted during a 1-year period in outpatient clinics of rehabilitation and physical medicine including 35 patients with moderate and severe CTS who receive ultrasonography-guided local steroid injection. The Boston self-assessment questionnaire and electrodiagnosis parameters were recorded at baseline, 1 month, and 3 months after therapy. We also recorded the baseline ultrasonography parameters to determine the predictors of outcome. Results: The sensory severity score and functional status scale along with electrodiagnosis parameters decreased significantly at 1 month (P < 0.001) and remained unchanged after 3 months. Volar bulging was negatively associated with sensory nerve action potential latency (r = −0.392; P = 0.020). Cross-sectional area (CSA) of maximal swelling (MS; r = 0.409; P = 0.015), CSA at 2-cm of MS (r = 0.563; P < 0.001), and CSA at 12-cm of MS (r = 0.521; P = 0.001) correlated positively with compound muscle action potential (CMAP) amplitude while maximal swelling/12-cm MS ratio (r = −0.439; P = 0.008) and maximal swelling/2-cm MS ratio (r = −0.342; P = 0.045) correlated negatively. CSA at 12-cm of MS also correlated positively with CMAP amplitude nerve conduction velocity (r = 0.436; P = 0.010). Conclusion: Volar bulging, CSA of maximal swelling, CSA of MS at 2-cm, and CSA of MS at 12-cm are among the ultrasonographic predictors of response to local steroid injection in patients with CTS.
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Affiliation(s)
- Farnaz Dehghan
- Department of Physical Medicine and Rehabilitation, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shila Haghighat
- Department of Physical Medicine and Rehabilitation, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hadiseh Ramezanian
- Department of Physical Medicine and Rehabilitation, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehdi Karami
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
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Atthakomol P, Manosroi W, Phanphaisarn A, Phrompaet S, Iammatavee S, Tongprasert S. Comparison of single-dose radial extracorporeal shock wave and local corticosteroid injection for treatment of carpal tunnel syndrome including mid-term efficacy: a prospective randomized controlled trial. BMC Musculoskelet Disord 2018; 19:32. [PMID: 29370788 PMCID: PMC5784684 DOI: 10.1186/s12891-018-1948-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 01/16/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Recent studies have reported that radial extracorporeal shock wave therapy (rESWT) reduces pain and improves function in patients with mild to moderately severe carpal tunnel syndrome (CTS) compared to a placebo. However, most of those studies used multi-session rESWT combined with wrist support and evaluation of efficacy was limited to a maximum of 14 weeks. METHODS The prospective randomized controlled trial compared efficacy in relieving pain and improving clinical function between single-dose rESWT and local corticosteroid injection (LCsI) over the mid-term (24 weeks). Twenty-five patients with mild to moderately severe CTS were randomized to receive either single-dose rESWT (n = 13) or LCsI (n = 12). Primary outcomes were evaluated using the Boston self-assessment questionnaire (BQ), while secondary outcomes used the Visual analogue scale (VAS) and electrodiagnostic parameters. Evaluations at baseline and at 1, 4, 12 and 24 weeks after treatment were performed. RESULTS There was significantly greater improvement in symptom severity scores, functional scores and Boston questionnaire scores at weeks 12 to 24 in the rESWT group compared to the LCsI group. When compared to the baseline, there was significant reduction of VAS and functional score in the rESWT group at weeks 12 and 24. The LCsI group had no statistically significant differences in VAS reduction and functional score of the same period. CONCLUSIONS Treatment of CTS using single-dose rESWT has a carry-over effect lasting up to 24 weeks suggesting that single-dose rESWT is appropriate for treatment of mild to moderate CTS and provides longer-lasting benefits than LCsI. TRIAL REGISTRATION ( TCTR20150709001 ). Registered 9 July 2015.
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Affiliation(s)
- Pichitchai Atthakomol
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Worapaka Manosroi
- Division of Endocrinology, Department of Internal Medicine, Bangkok Chiang Mai Hospital, Chiang Mai, Thailand
| | - Areerak Phanphaisarn
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sureeporn Phrompaet
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sawan Iammatavee
- Department of Orthopaedics, Nakornping Hospital, Chiang Mai, Thailand
| | - Siam Tongprasert
- Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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