Assessment of phonophoresis and iontophoresis in the treatment of carpal tunnel syndrome: a randomized controlled trial

Effect of Contractubex phonophoresis on postsurgical scar of carpal tunnel release: A case report

Key Clinical Message

Contractubex phonophoresis can be used in clinical setting to manage postsurgical scar after carpal tunnel release. Contractubex phonophoresis can improve pliability, height, and tenderness of the scar.

Abstract

Scar is one of the most common complications after open release of carpal tunnel. Scars are mentally and physically disturbing, and they can result into itching and pain. Scar after release of carpal tunnel can lead to compression of median nerve and failure of surgery. Various treatments are suggested for scar management. topical drugs are one of these treatments. Phonophoresis of topical drugs can enhance delivery of topical drugs. In present case, author report the effect of phonophoresis of Contractubex on postsurgical scar after carpal tunnel release. Result indicated that phonophoresis of Contractubex can be effective in scar management.

Use of Iontophoresis with Corticosteroid in Carpal Tunnel Syndrome: Systematic Review and Meta-Analysis

BACKGROUND

Carpal tunnel syndrome is a neuropathy that affects the median nerve. The aim of this review is to synthesize the evidence and perform a meta-analysis on the effects of iontophoresis in people with carpal tunnel syndrome.

METHODS

The search was carried out using PubMed, Web of Science, Scopus, CINHAL Complete, Physiotherapy Evidence Database, and SciELO. The methodological quality was evaluated using PEDro. A standardized or mean difference meta-analysis (Hedge's g) using a random-effects model was calculated.

RESULTS

Seven randomized clinical trials using iontophoresis for electrophysiological, pain, and functional outcomes were included. The mean of PEDro was 7/10. No statistical differences were obtained for the median sensory nerve conduction velocity (SMD = -0.89; p = 0.27) or latency (SMD = -0.04; p = 0.81), motor nerve conduction velocity (SMD = -0.04; p = 0.88) or latency (SMD = -0.01; p = 0.78), pain intensity (MD = 0.34; p = 0.59), handgrip strength (MD = -0.97; p = 0.09), or pinch strength (SMD = -2.05; p = 0.06). Iontophoresis only seemed to be superior in sensory amplitude (SMD = 0.53; p = 0.01).

CONCLUSIONS

Iontophoresis did not obtain an enhanced improvement compared to other interventions, but no clear recommendations could be made due to the limited number of included studies and the heterogeneity found in the assessment and intervention protocols. Further research is needed to draw sound conclusions.

Use of Sonophoresis with Corticosteroids in Carpal Tunnel Syndrome: Systematic Review and Meta-Analysis

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.

Ultrasound improves motor distal latency on patients with carpal tunnel syndrome: systematic review and meta-analysis

INTRODUCTION

Is the application of ultrasound effective on pain, the severity of the symptoms, physical function, strength, and neurophysiological parameters of the median nerve conduction in patients with carpal tunnel syndrome?

EVIDENCE ACQUISITION

A systematic review and meta-analysis of randomized controlled trials was performed by using a structured search strategy in Scopus, CINAHL, Web of Science and PEDro databases. All the primary studies included samples with carpal tunnel syndrome treated by: ultrasound versus no treatment, therapeutic ultrasound versus sham ultrasound, ultrasound and usual care versus usual care, or ultrasound and other intervention versus the same intervention. The outcomes measures registered were pain, severity of symptoms, function, strength, and neurophysiological parameters (motor distal latency and sensory distal latency) of the median nerve. Methodological quality was evaluated by PEdro Scale.

EVIDENCE SYNTHESIS

Ten clinical trials met the inclusion criteria for the systematic review. Eight trials were meta-analyzed, which included a total of 2069 patients with carpal tunnel syndrome. The methodological quality of the included studies ranged among limited (5 trials), moderate (3 trials), and high (2 trials). In one of the electrophysiological parameters (motor distal latency), a significant difference between groups after the use of ultrasound was observed (MD=-0.10; fixed 95% CI=-0.20, -0.01; P=0.04). No significant differences between groups were observed at post-treatment for pain (P=0.29), severity of symptoms (P=0.99), function (P=0.54), strength (P=0.27) and for the rest of the electrophysiological parameters evaluated (P>0.05).

CONCLUSIONS

The use of ultrasound on patients with carpal tunnel syndrome seems to improve motor distal latency. This finding implies a partial improvement at the neurophysiological level, representing a reduction in the grade of clinical severity. Additional clinical trials with a high methodological quality are needed to investigate the doses at which ultrasound are most effective.

A randomized comparative trial of corticosteroid phonophoresis, local corticosteroid injection, and low-level laser in the treatment of carpal tunnel syndrome

Background and aims

Carpal tunnel syndrome is the most prevalent peripheral neuropathy and has a considerable burden on health services. We tried to compare the therapeutic effects of local corticosteroid injection, low-level laser, and corticosteroid phonophoresis in the treatment of carpal tunnel syndrome.

Subjects and methods

We performed a randomized clinical trial with three parallel groups. The study was carried out at a University Hospital. In total, 42 participants including 31(73.8%) women were randomly allocated to the treatment groups with equal sizes. We assessed pain, symptom severity and functional status with Boston Carpal Tunnel Questionnaire, and performed median nerve conduction velocity studies. Evaluations were done before the interventions and in the fourth week of study. For the group corticosteroid, under the guidance of sonography, methylprednisolone with lidocaine was injected into the carpal tunnel. For laser therapy, we administered 10 sessions, each lasting 10 seconds. We used topical hydrocortisone acetate gel 10% as the anti-inflammatory agent with phonophoresis, 3 times per week for 10 sessions.

Results

Within-group analyses with paired t-test showed that local corticosteroid, laser, and phonophoresis are all effective treatments. Between-group analyses with ANOVA indicated that there were significant differences among the groups after four weeks in terms of pain (p = 0.004), in favor of corticosteroid; and in sensory delay (p = 0.001), in favor of laser. For the Boston Carpal Tunnel Questionnaire and median nerve motor latency, the results were not significant. There was no important side-effect after four weeks of follow-up.

Conclusion

The three treatments are comparable and beneficial for carpal tunnel syndrome.

The results of surgical decompression in the treatment of foot drop due to peroneal nerve entrapment after bariatric surgery

BACKGROUND

The loss of the fat pad surrounding the fibular head after rapid and excessive weight loss after bariatric surgery can lead to foot drop symptoms due to peroneal nerve entrapment (PNE). Conservative and surgical approaches have been described for the treatment of this condition, but there is some controversy over the effectiveness of the treatment modalities.

OBJECTIVE

We aimed to investigate the causes and frequency of foot drop due to PNE after bariatric surgery and to investigate the effects of peroneal nerve decompression (PND) as a surgical treatment for PNE.

SETTING

Single center, university surgical department.

METHODS

We retrospectively evaluated a series of 2607 patients in terms of neurologic complications after bariatric surgery. Patients' age, sex, co-morbid diseases, vitamin and electrolyte levels, body mass index and postoperative excess weight loss, affected limb, duration of symptoms, and muscle strength scores (according to the Medical Research Council scale) were recorded.

RESULTS

A total of 14 (.5%) patients had foot drop symptoms due to PNE. Of these patients, 9 underwent PND. The mean excess weight loss of PND patients at postoperative months 6 and 12 were 68.8 ± 13.5 and 100.9 ± 10.8, respectively. Foot drop symptoms became evident 5 to 11 months after bariatric surgery, affecting only a unilateral lower extremity in all patients. In laboratory analysis, there were no signs of nutritional and vitamin deficiency or insufficiency in any of the PND cases. Muscular strength was Medical Research Council grade 0 in all patients. The median duration of symptoms was 9 days, and the median complete recovery time was 40 days after PND. Patients who had a duration of symptoms for a maximum of 12 days were completely healed 30 days after PND.

CONCLUSION

PND should be the first-choice treatment procedure for acute foot drop due to PNE after bariatric surgery.

Linking commonly used hand therapy outcome measures to individual areas of the International Classification of Functioning: A systematic review

STUDY DESIGN

Systematic review.

INTRODUCTION

Identifying outcome measures that correspond to the International Classification of Functioning (ICF) provides insight into selecting appropriate outcome tools in hand therapy practice.

PURPOSE OF THE STUDY

The objective of this study is to systematically review patient-reported outcome measures commonly used in hand therapy to determine the extent to which the content represents the biopsychosocial view of the ICF.

METHODS

A comprehensive literature search was conducted. Studies that met inclusion criteria were identified, and outcome measures were extracted. The meaningful concept was determined for each item on the measure and linked to the most specific ICF category. Summary linkage calculations were completed.

RESULTS

Eleven patient-reported outcomes were identified from 43 included studies. Activity and participation had the highest content coverage followed by body functions. There was linking to personal factors and not defined-disability and mental health. Environmental factors were not represented in any of the included outcome measures. The core set representation of unique codes ranged from 8.55% to 18.80% (mean: 11.97%) for the Comprehensive ICF Core Set for Hand Conditions and from 30.43% to 47.83% (mean: 31.40%) for the Brief ICF Core Set for Hand Conditions. The percent representation of the Comprehensive ICF Core Set for Hand Conditions for unique disability ranged from 21.62% to 43.24% (mean: 20.33%) and from 62.50% to 87.50% (mean: 72.22%) for the Brief ICF Core Set for Hand Conditions.

DISCUSSION

None of the included measures represent all categories of the ICF Core Sets for Hand Conditions.

CONCLUSION

Utilizing the most recent refinement rules for the linking process, this study provides comparisons of measures along with clarity of content coverage for the most commonly used tools in the practice of hand therapy.

Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome

The Academy of Orthopaedic Physical Therapy and the Academy of Hand and Upper Extremity Physical Therapy have an ongoing effort to create evidence-based clinical practice guidelines (CPGs) for orthopaedic and sports physical therapy management and prevention of musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability and Health (ICF). This particular guideline focuses on hand pain and sensory deficits in carpal tunnel syndrome. J Orthop Sports Phys Ther 2019;49(5):CPG1-CPG85. doi:10.2519/jospt.2019.0301.

Comparative short-term effectiveness of ibuprofen gel and cream phonophoresis in patients with knee osteoarthritis

The objective of the present study was to compare the effectiveness of gel and cream ibuprofen phonophoresis in patients with knee osteoarthritis. A single-blinded, randomized, comparative design was applied. Patients diagnosed with knee osteoarthritis according to the American College of Rheumatology criteria were included in the study. After obtaining written informed consent, patients were randomized into ibuprofen gel and cream phonophoresis groups. Each patient was treated five sessions per week for 2 weeks (ten sessions). Main outcome measures were 100 mm visual analogue scale (VAS) for pain and the disease-specific questionnaire; Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Sixty-one knee osteoarthritis patients with a mean age of 57.9 ± 9.7 years were included in the study. Baseline VAS and WOMAC scores were similar between gel (n = 30) and cream (n = 31) phonophoresis groups (p > 0.05 for both). Following the treatment, both groups showed improvement compared to baseline measures including VAS pain and WOMAC scores. In the gel phonophoresis group, the improvement in VAS score was higher than that observed in the cream phonophoresis group (p < 0.001). Similarly, the improvement in WOMAC total score was also higher in the gel phonophoresis group (p < 0.001). Ibuprofen phonophoresis is clinically effective in patients with knee osteoarthritis. Phonophoresis using the gel form of ibuprofen is associated with more clinical improvement than that using the cream form of the same molecule.

Carpal Tunnel Syndrome: Effectiveness of Physical Therapy and Electrophysical Modalities. An Updated Systematic Review of Randomized Controlled Trials

OBJECTIVE

To review scientific literature studying the effectiveness of physical therapy and electrophysical modalities for carpal tunnel syndrome (CTS).

DATA SOURCES

The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database.

STUDY SELECTION

Two reviewers independently applied the inclusion criteria to select potential eligible studies.

DATA EXTRACTION

Two reviewers independently extracted the data and assessed the methodologic quality using the Cochrane Risk of Bias Tool.

DATA SYNTHESIS

A best-evidence synthesis was performed to summarize the results of the included studies (2 reviews and 22 randomized controlled trials [RCTs]). For physical therapy, moderate evidence was found for myofascial massage therapy versus ischemic compression on latent, or active, trigger points or low-level laser therapy in the short term. For several electrophysical modalities, moderate evidence was found in the short term (ultrasound vs placebo, ultrasound as single intervention vs other nonsurgical interventions, ultrasound vs corticosteroid injection plus a neutral wrist splint, local microwave hyperthermia vs placebo, iontophoresis vs phonophoresis, pulsed radiofrequency added to wrist splint, continuous vs pulsed vs placebo shortwave diathermy, and interferential current vs transcutaneous electrical nerve stimulation vs a night-only wrist splint). In the midterm, moderate evidence was found in favor of radial extracorporeal shockwave therapy (ESWT) added to a neutral wrist splint, in favor of ESWT versus ultrasound, or cryo-ultrasound, and in favor of ultrasound versus placebo. For all other interventions studied, only limited, conflicting, or no evidence was found. No RCTs investigating the long-term effects of physical therapy and electrophysical modalities were found. Because of heterogeneity in the treatment parameters used in the included RCTs, optimal treatment parameters could not be identified.

CONCLUSIONS

Moderate evidence was found for several physical therapy and electrophysical modalities for CTS in the short term and midterm. Future studies should concentrate on long-term effects and which treatment parameters of physical therapy and electrophysical modalities are most effective for CTS.

Effectiveness of Occupational Therapy Interventions for Adults With Musculoskeletal Conditions of the Forearm, Wrist, and Hand: A Systematic Review

Occupational therapy practitioners are key health care providers for people with musculoskeletal disorders of the distal upper extremity. It is imperative that practitioners understand the most effective and efficient means for remediating impairments and supporting clients in progressing to independence in purposeful occupations. This systematic review provides an update to a previous review by summarizing articles published between 2006 and July 2014 related to the focused question, What is the evidence for the effect of occupational therapy interventions on functional outcomes for adults with musculoskeletal disorders of the forearm, wrist, and hand? A total of 59 articles were reviewed. Evidence for interventions was synthesized by condition within bone, joint, and general hand disorders; peripheral nerve disorders; and tendon disorders. The strongest evidence supports postsurgical early active motion protocols and splinting for various conditions. Very few studies have examined occupation-based interventions. Implications for occupational therapy practice and research are provided.

Effects of underwater ultrasound therapy on pain, inflammation, hand function and quality of life in patients with rheumatoid arthritis - a randomized controlled trial

•

Underwater ultrasound therapy is a useful procedure to treat inflammation in patients with RA.

•

Underwater ultrasound therapy is suitable to treat irregular body parts, because the transmission coefficient is high and the reflection is low in water.

•

The improvements were only observed in the short term (at the end of 2 weeks of treatment).

Objectives

To investigate the effects of underwater ultrasound (US) therapy in 48 patients with moderately active rheumatoid arthritis (disease activity score in 28 joints [DAS28] > 3.2 and < 5.1).

Methods

Patients randomly assigned to the ultrasound group (n = 25) received underwater continuous ultrasound therapy to both wrists and hands for 7 min per session with an intensity of 0.7 W/cm² for 10 sessions. The control group (n = 23) received sham treatment under the same conditions. At baseline, at the end of treatment (end of Week 2) and at the follow-up visit (Week 14), the following outcomes were evaluated: disease activity (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], tender and swollen joint counts, pain on a visual analog scale, DAS28, hand function (fist making, wrist extension and flexion, hand grip strength) and quality of life (Health Assessment Questionnaire [HAQ]).

Results

A significant decrease in C-reactive protein at the end of Week 2 and Week 14 compared to control group (mean between-group difference at 2 weeks = −5.77, 95% CI = −10.86 to −0.68, mean between-group difference at 14 weeks = −5.07, 95% CI = −10.13 to −0.01), and non-significant decrease in DAS28 was observed. By the end of treatments at the end of week 2, ultrasound alleviated pain significantly (mean between-group difference at two weeks = −8.35 95% CI = −16.12 to −0.58), as well as improved left wrist extension compared to the control group (mean between-group difference at 14 weeks = 4.35, 95% CI = 1.09–7.60).

Conclusion

Underwater ultrasound therapy was better than sham treatment at the end of 2 weeks of treatment, but not at long term (14 weeks) in patients with rheumatoid arthritis.

Clinical trial registration number: NCT02706028 (https://clinicaltrials.gov/ct2/show/NCT02706028)

A structured literature synthesis of wrist outcome measures: An evidence-based approach to determine use among common wrist diagnoses

STUDY DESIGN

Structured literature synthesis.

INTRODUCTION

Hand therapists and researchers have numerous options when selecting outcome measures for patients with wrist pathologies. An evidence-based approach to determining which measures are used most often can inform choices.

PURPOSE OF THE STUDY

To describe how frequently outcome measures are used in recent randomized controlled trials of patients with wrist diagnoses. Identifying assessment design and related International Classification of Functioning, Disability and Health (ICF) domains provides additional consideration for selection.

METHODS

Systematic PubMed and Cumulative Index to Nursing and Allied Health Literature searches for the time frame between January 2005 and March 2015 captured measures used in randomized controlled trials researching wrist-specific fractures, ligament injuries, nerve injuries, arthritis/arthroplasty, or stress injuries/wrist pain.

RESULTS

Three most frequent measures used within each diagnostic category are detailed with assessment design described and ICF domain identified. Across diagnoses, grip/pinch strength and Disabilities of Arm, Shoulder and Hand were the most frequently used physical and patient-reported outcome measures, respectively. The Jebsen-Taylor Hand Function Test was the most frequently used performance measure.

DISCUSSION AND CONCLUSIONS

Consideration of the evidence, ICF domains, wrist diagnoses, and assessment design can help hand therapists select the measure most appropriate for use.

LEVEL OF EVIDENCE

2a.

Carpal tunnel syndrome: clinical features, diagnosis, and management

Carpal tunnel syndrome is the most common peripheral nerve entrapment syndrome worldwide. The clinical symptoms and physical examination findings in patients with this syndrome are recognised widely and various treatments exist, including non-surgical and surgical options. Despite these advantages, there is a paucity of evidence about the best approaches for assessment of carpal tunnel syndrome and to guide treatment decisions. More objective methods for assessment, including electrodiagnostic testing and nerve imaging, provide additional information about the extent of axonal involvement and structural change, but their exact benefit to patients is unknown. Although the best means of integrating clinical, functional, and anatomical information for selecting treatment choices has not yet been identified, patients can be diagnosed quickly and respond well to treatment. The high prevalence of carpal tunnel syndrome, its effects on quality of life, and the cost that disease burden generates to health systems make it important to identify the research priorities that will be resolved in clinical trials.

Effect of carpal tunnel syndrome on grip and pinch strength compared with sex- and age-matched normative data

OBJECTIVE

To compare grip and pinch strength of individuals with carpal tunnel syndrome (CTS) to normative values before and after a combined splint/stretching intervention.

METHODS

Data collected on grip and pinch strength on 124 subjects with CTS were compared to age- and sex-matched normative data.

RESULTS

In general, our sample had significantly lower strength than the normative sample at baseline. Although there were significant improvements in strength after 4 weeks of splinting/exercise, subjects continued to have significant deficits in comparison to the normative data.

CONCLUSION

Patients with CTS have moderate to large deficits in grip and pinch strength in comparison to normative data. Splinting/stretching may reduce these deficits; however, CTS patients are often left with residual problems at 4 weeks.

Therapeutic ultrasound for carpal tunnel syndrome

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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