The efficacy of phonophoresis on electrophysiological studies of the patients with carpal tunnel syndrome

Comparison of the Effect of Intracarpal Injection of Ketorolac With Triamcinolone in Carpal Tunnel Syndrome: A Randomized Controlled Trial

BACKGROUND

The most prevalent entrapment neuropathy is carpal tunnel syndrome (CTS). Although nonsteroidal antiinflammatory drugs (NSAIDs) are frequently prescribed for musculoskeletal disorders, oral NSAIDs do not provide any additional benefits for CTS. Nevertheless, the use of NSAID phonophoresis has shown significant improvement, possibly due to increased concentration in the target tissue. The effects of intracarpal injection of NSAIDs on CTS have not been studied.

OBJECTIVE

We conducted a controlled trial to compare the efficacy of ketorolac and triamcinolone in treating CTS.

METHODS

Mild to moderate CTS patients were randomly assigned to receive either a local injection of 30 mg ketorolac or 40 mg triamcinolone. Patients were evaluated using visual analog scale (VAS) for pain, severity, function, electrodiagnostic findings, patient satisfaction, and any complications at the injection site, at baseline and 12 weeks after the procedures.

RESULTS

Fifty patients participated, and 43 completed the study. Both groups showed significant improvement in the VAS, severity, function, and electrodiagnostic scores at 3 months compared with the baseline. A comparison of the groups showed significant differences in VAS, severity, and function, with the improvement being significantly higher in the triamcinolone group.

CONCLUSION AND RELEVANCE

The present study showed that injection of triamcinolone or ketorolac into the carpal tunnel relieved pain, increased function, and improved electrodiagnostic findings in patients with mild to moderate CTS. It also showed that triamcinolone was superior to ketorolac in terms of analgesic effect and resulted in greater improvement in symptom severity and function.

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.

Nonsurgical Treatment for Symptomatic Carpal Tunnel Syndrome: A Randomized Clinical Trial Comparing Local Corticosteroid Injection Versus Night Orthosis

PURPOSE

For carpal tunnel syndrome (CTS), local corticosteroid injection (corticosteroid), and/or wrist immobilization with night orthosis (orthosis) are commonly prescribed and are supported by strong evidence. The aim of this study was to compare orthosis versus corticosteroid for patients with CTS.

METHODS

A CTS diagnosis was made clinically and supported by electrodiagnostic study. Patients were randomly allocated to either orthosis or corticosteroid. Clinical assessments were performed before the intervention, within the first week of the intervention, and 1, 3, and 6 months after the intervention. Primary outcomes were improvement in nocturnal paresthesia and Boston-Levine questionnaire (BLQ) score. Secondary outcomes were pain assessed by visual analog scale and complications.

RESULTS

Of 100 patients enrolled in the study, 95 completed the planned follow-up (45 in the orthosis arm and 50 in the corticosteroid arm). Corticosteroid injections were superior to orthosis in remission of nocturnal paresthesia (remission rates at 1 month, 84.6% versus 43.83%; 3 months, 71.1% versus 40.4%; and 6 months, 80.3% versus 28.8%). The BLQ scores (functional and symptom subscales) were also more favorable for corticosteroid at 1, 3, and 6 months (minimal clinically important differences for Function > 0.5 and Symptom > 0.16). Pain scores were lower and favored the corticosteroid group. There were no complications in either group.

CONCLUSIONS

Both options are effective in the short term. Corticosteroid is superior to orthosis for improving CTS-related nocturnal paresthesia, BLQ scores, and pain.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

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.

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.

Effectiveness of Phonophoresis Treatment in Carpal Tunnel Syndrome: A Randomized Double-blind, Controlled Trial

OBJECTIVE

To determine the effects of phonophoresis of piroxicam (PH-P) and phonophoresis of dexamethasone sodium phosphate (PH-Dex) on mild to moderate carpal tunnel syndrome (CTS), and to compare each of them with the control group of nondrug ultrasound (US) therapy.

DESIGN

A randomized, double-blind controlled trial.

SETTING

Department of rehabilitation medicine, university hospital.

PARTICIPANTS

Patients with clinical signs and symptoms of CTS underwent an electrophysiological study to confirm the diagnosis of CTS and severity grading. Thirty-three patients, 50 hands (52% of the patients had bilateral CTS, n = 17) with mild to moderate CTS were randomly allocated into three study groups: PH-P, PH-Dex, or US.

INTERVENTION

All three groups received 10 sessions of 1-MHz frequency, 1.0 w/cm² intensity ultrasound wave with stroking technique, continuous mode, at the palm side of the hand over the carpal tunnel area-10 minutes per session, two to three times per week for 4 weeks, for a total of 10 sessions. During each session, the patients received 15 cm³ of study gel according to the study groups. The PH-P group received 0.5% piroxicam gel mixture (equivalence of 20 mg of piroxicam). The PH-Dex group received 0.4% dexamethasone sodium phosphate gel mixture (equivalence 60 mg of dexamethasone). The US group received nondrug gel.

MAIN OUTCOME MEASUREMENTS

Boston Carpal Tunnel Questionnaire for symptom severity (BCTQ SYMPT), Boston Carpal Tunnel Questionnaire for functional status (BCTQ FUNCT) and electrophysiological parameters of the median nerve including distal sensory latency (DSL) and distal motor latency (DML) were evaluated before the first treatment and after the last treatment.

RESULTS

After treatment, all treatment groups (PH-P, PH-Dex, and US) showed significant improvements of the BCTQ SYMPT (P < .001, -0.74 ± 0.73 [-1.12, -0.37], -0.91 ± 0.96 [-1.41, -0.42], and - 0.68 ± 0.71 [-1.05, -0.30], respectively) and the BCTQ FUNCT (P < .001, -0.68 ± 0.89 [-1.14, -0.22], -0.74 ± 0.84 [-1.17, -0.30], and - 0.80 ± 0.80 [-1.22, -0.37], respectively). For the BCTQ SYMPT, only the PH-Dex showed an improvement score above MCID at 0.8 level [-0.91 ± 0.96]. The improvement of BCTQ FUNCT score of all groups was above Minimal Clincally Important Difference (MCID) at 0.5 level (-0.68 ± 0.89, -0.74 ± 0.84 and - 0.80 ± 0.80, respectively).The DSL was decreased in all groups but the changes were not statistically significant (P = .70, -0.11 ± 0.34 [-0.28, 0.06], -0.09 ± 0.32 [-0.26, 0.07], and - 0.14 ± 0.29 [-0.29, 0.02], respectively). The DML showed decrease only in PH-DEX and the US group but it was not statistically significant (P = .68, 0.05 ± 0.44 [-0.17, 0.27], -0.09 ± 0.51[-0.34, 0.17], and - 0.27 ± 0.49 [-0.53, 0.01], respectively). All measured outcomes were not statistically different in between-group-comparison of BCTQ SYMPT, BCTQ FUNCT, DSL, and DML (P = .58, P = .79, P = .20 and P = .39, respectively). However, there was a clinically significant difference of the improvement of BCTQ SYMPT in between-group comparison; only the PH-DEX was above the MCID level, while the PH-P and US were not.

CONCLUSIONS

Neither nondrug US nor phonophoresis treatments (PH-P and PH-Dex) were effective to improve the DSL and DML in mild to moderate CTS. All three groups showed significant improvements in clinical symptoms (BCTQ SYMPT) and functional status (BCTQ FUNCT). At 1 MHz frequency and 1.0 w/cm² intensity of ultrasound wave, there is no statistically significant difference between phonophoresis and the nondrug US.

LEVEL OF EVIDENCE

I.

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.

Evidence-based medicine: Carpal tunnel syndrome

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) Describe and apply the best current high-level evidence in carpal tunnel syndrome. (2) Design a treatment plan to offer tourniquet-free, sedation-free local anesthesia for patients who wish it or who are at high risk with sedation. (3) Describe the evidence and outcomes as they relate to splinting carpal tunnel patients after surgery.

SUMMARY

This is the third Maintenance of Certification article on carpal tunnel syndrome. Hentz and Lalonde summarized the best literature in 2008 in the first article. The second article, by Shores and Lee, presented the best evidence regarding assessment, surgical treatment, and outcomes from the literature published between 1999 and 2009. In this article, the author has concentrated on topics not covered in depth in the first two articles and provides an update of the highest level evidence on important topics from 2009 to 2013. Although there is some Level IV and V evidence cited in this article, most is Level I, II, and III.