Treatment of carpal tunnel syndrome by low-level laser versus open carpal tunnel release

Surgical versus non-surgical treatment for carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is a compression neuropathy of the median nerve at the wrist. Surgery is considered when symptoms persist despite the use of non-surgical treatments. It is unclear whether surgery produces a better outcome than non-surgical therapy. This is an update of a Cochrane review published in 2008.

OBJECTIVES

To assess the evidence regarding the benefits and harms of carpal tunnel release compared with non-surgical treatment in the short (< 3 months) and long (> 3 months) term.

SEARCH METHODS

In this update, we included studies from the previous version of this review and searched the Cochrane Neuromuscular Specialised Register, CENTRAL, Embase, MEDLINE, ClinicalTrials.gov and WHO ICTRP until 18 November 2022. We also checked the reference lists of included studies and relevant systematic reviews for studies.

SELECTION CRITERIA

We included randomised controlled trials comparing any surgical technique with any non-surgical therapies for CTS.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

The 14 included studies randomised 1231 participants (1293 wrists). Eighty-four per cent of participants were women. The mean age ranged from 32 to 53 years, and the mean duration of symptoms from 31 weeks to 3.5 years. Trial sizes varied from 22 to 176 participants. The studies compared surgery with: splinting, corticosteroid injection, splinting and corticosteroid injection, platelet-rich plasma injection, manual therapy, multimodal non-operative treatment, unspecified medical treatment and hand support, and surgery and corticosteroid injection with corticosteroid injection alone. Since surgery is generally used for its long-term effects, this abstract presents only long-term results for surgery versus splinting and surgery versus corticosteroid injection. 1) Surgery compared to splinting in the long term (> 3 months) Surgery probably results in a higher rate of clinical improvement (risk ratio (RR) 2.10, 95% confidence interval (CI) 1.04 to 4.24; 3 studies, 210 participants; moderate-certainty evidence). Surgery probably does not provide clinically important benefit in symptoms or hand function compared with splinting (moderate-certainty evidence). The mean Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (scale 1 to 5; higher is worse; minimal clinically important difference (MCID) = 1) was 1.54 with splint and 0.26 points better with surgery (95% CI 0.52 better to 0.01 worse; 2 studies, 195 participants). The mean BCTQ Functional Status Scale (scale 1 to 5; higher is worse; MCID 0.7) was 1.75 with splint and 0.36 points better with surgery (95% CI 0.62 better to 0.09 better; 2 studies, 195 participants). None of the studies reported pain. Surgery may not provide better health-related quality of life compared with splinting (low-certainty evidence). The mean EQ-5D index (scale 0 to 1; higher is better; MCID 0.074) was 0.81 with splinting and 0.04 points better with surgery (95% CI 0.0 to 0.08 better; 1 study, 167 participants). We are uncertain about the risk of adverse effects (very low-certainty evidence). Adverse effects were reported amongst 60 of 98 participants (61%) in the surgery group and 46 of 112 participants (41%) in the splinting group (RR 2.11, 95% CI 0.37 to 12.12; 2 studies, 210 participants). Surgery probably reduces the risk of further surgery; 41 of 93 participants (44%) were referred to surgery in the splinting group and 0 of 83 participants (0%) repeated surgery in the surgery group (RR 0.03, 95% CI 0.00 to 0.21; 2 studies, 176 participants). This corresponds to a number needed to treat for an additional beneficial outcome (NNTB) of 2 (95% CI 1 to 9). 2) Surgery compared to corticosteroid injection in the long term (> 3 months) We are uncertain if clinical improvement or symptom relief differs between surgery and corticosteroid injection (very low-certainty evidence). The RR for clinical improvement was 1.23 (95% CI 0.73 to 2.06; 3 studies, 187 participants). For symptoms, the standardised mean difference (SMD) was -0.60 (95% CI -1.88 to 0.69; 2 studies, 118 participants). This translates to 0.4 points better (95% CI from 1.3 better to 0.5 worse) on the BCTQ Symptom Severity Scale. Hand function or pain probably do not differ between surgery and corticosteroid injection (moderate-certainty evidence). For function, the SMD was -0.12 (95% CI -0.80 to 0.56; 2 studies, 191 participants) translating to 0.10 points better (95% CI 0.66 better to 0.46 worse) on the BCTQ Functional Status Scale with surgery. Pain (0 to 100 scale) was 8 points with corticosteroid injection and 6 points better (95% CI 10.45 better to 1.55 better; 1 study, 123 participants) with surgery. We found no data to estimate the difference in health-related quality of life (very low-certainty evidence). We are uncertain about the risk of adverse effects and further surgery (very low-certainty evidence). Adverse effects were reported amongst 3 of 45 participants (7%) in the surgery group and 2 of 45 participants (4%) in the corticosteroid injection group (RR 1.49, 95% CI 0.25 to 8.70; 2 studies, 90 participants). In one study, 12 of 83 participants (15%) needed surgery in the corticosteroid group, and 7 of 80 participants (9%) needed repeated surgery in the surgery group (RR 0.61, 95% CI 0.25 to 1.46; 1 study, 163 participants).

AUTHORS' CONCLUSIONS

Currently, the efficacy of surgery in people with CTS is unclear. It is also unclear if the results can be applied to people who are not satisfied after trying various non-surgical options. Future studies should preferably blind participants from treatment allocation and randomise people who are dissatisfied after being treated non-surgically. The decision for a patient to opt for surgery should balance the small benefits and potential risks of surgery. Patients with severe symptoms, a high preference for clinical improvement and reluctance to adhere to non-surgical options, and who do not consider potential surgical risks and morbidity a burden, may choose surgery. On the other hand, those who have tolerable symptoms, who have not tried non-surgical options and who want to avoid surgery-related morbidity can start with non-surgical options and have surgery only if necessary. We are uncertain if the risk of adverse effects differs between surgery and non-surgical treatments. The severity of adverse effects may also be different.

Photobiomodulation Therapy in Carpal Tunnel Release: A Randomized Controlled Trial

Background: Carpal tunnel release (CTR) is widely accepted as an effective treatment for carpal tunnel syndrome. However, the recovery is often delayed and incomplete. Photobiomodulation therapy (PBMT) produces a nonthermal effect on living tissues; it promotes healing, remodels and reduces inflammation of an injured nerve. The purpose of this study was to compare the outcome of CTR between patients who underwent postoperative PBMT and without PBMT. Materials and methods: We recruited 105 patients who had open CTR from January 2019 to January 2021. Fifty-six patients fulfilled the study criteria and were randomized into two groups: with PBMT (n = 28) and without PBMT (n = 28). Demographic and clinical data were obtained preoperatively. The PBMT group had ten 3-min sessions over 3 weeks using 808 nm, 50 mW PBMT to deliver 9 J per session to the CTR incision scar. Clinical outcomes were assessed at 1, 3, and 6 months postoperatively. Data analysis was performed with SPSS software. Results: There were significant improvements in the Functional Status Scale in the Boston Carpal Tunnel Questionnaire (p = 0.018) and pain (visual analogue scales) in the morning (p = 0.019) at 1 month postoperatively in the PBMT group compared with the non-PBMT group. Improvement of tip pinch strength at 3 months (p = 0.022) and 6 months (p = 0.024), lateral pinch strength at 1 month (p = 0.042) and 3 months (p = 0.05), and tripod pinch strength at 3 months (p = 0.005) was significantly better in the PBMT group. Thumb 2-point discrimination (2PD) at 3 months (p = 0.018) and 6 months (p = 0.016) and index finger 2PD at 3 months (p = 0.039) were also significantly improved in the PBMT group. There were no side effects of PBMT reported. Conclusions: Patients who underwent PBMT post-CTR had better outcomes. PBMT may be a valuable adjunct to post-CTR care.

Treatment of carpal tunnel syndrome by low-level laser therapy versus corticosteroid injection: a randomized, prospective clinical study

To compare the effects of low level laser therapy (LLLT) and corticosteroid injection in patients with moderate carpal tunnel syndrome (CTS). Eighty-seven patients (143 wrists) with moderate CTS were randomized to the corticosteroid or LLLT groups. 40 mg of triamcinolone acetate solution was applied to carpal tunnel of 44 patients (74 wrist). LLLT was applied to 43 patients (70 wrist) five times a week, for a total of 15 sessions (fluence of 6 j/cm² for 1 min per point at a wavelength of 830 nm). Outcome measures were numbness and pain, QuickDASH questionnaire, grasping tests, Tinel and Phalen tests, electrophysiological tests and MRI evaluations, which were tested at the baseline and 1st and 6th months after the treatment. Eighty patients (133 wrists) completed the study at the end of 6 months. VAS and Quick DASH scores were better in the corticosteroid group in the 1st month, but there were no significant differences between groups in the 6th month. Phalen and Tinel tests, strength tests, and motor distal latency improved significantly and similarly in both groups at the 1st and 6th months. Sensory distal latency and sensory nerve conduction velocity showed significant improvements in the 1st and 6th months only in the corticosteroid group. In both groups, median nerve intensity rate and palmary spring rate improved significantly after the treatment. Based on this study, corticosteroid injection and LLLT groups showed statistically significant difference at the 1st month (short-term), whereas there was no significant difference at the 6th month (intermediate-term).

A comparative study of the dose-dependent effects of low level and high intensity photobiomodulation (laser) therapy on pain and electrophysiological parameters in patients with carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is a common peripheral nerve disorder of the wrist. Nonsurgical treatments e.g. laser therapy may cause potential beneficial effects.

AIM

To compare the dose dependent effects of low level laser therapy (LLLT) and high intensity laser therapy (HILT) on pain and electrophysiology studies in patients with CTS.

DESIGN

Double-blind randomized controlled trial.

SETTING

Outpatient physiotherapy clinic.

POPULATION

Ninety-eight participants with CTS, aged between 20 to 60 years, were randomly assigned to five groups.

METHODS

All participants undertook four standard exercises, with one group serving as exercise-only controls. Patients were randomly allocated to either high or low fluence LLLT or high or low fluence HILT received over 5 sessions. All patients were assessed by visual analogue scale, median compound muscle action potential (CMAP) and sensory nerve conduction studies before and 3 weeks after the interventions.

RESULTS

VAS was significantly lower in all groups after 3 weeks (P<0.05). CMAP latency decreased in all groups. The interaction of group and time (5×2) was significant for pain (P<0.001), the latency of CMAP (P=0.001) and CMAP amplitude (P=0.02). The interaction of group and time was not significant for the CMAP conduction velocity, sensory nerve latency and amplitude (P>0.05).

CONCLUSIONS

HILT with a power of 1.6 W and low fluence of 8 J/cm² was superior in reduction of pain and improvement of the median motor nerve electrophysiological studies compared to LLLT and exercise-only control groups.

CLINICAL REHABILITATION IMPACT

LLLT and HILT in conjunction with exercise program are effective in reducing pain and improving median motor nerve conduction studies of the patients with CTS. It seems that high power and low fluence laser therapy is better than LLLT and exercise interventions to treat these patients.

Effectiveness of surgical versus conservative treatment for carpal tunnel syndrome: A systematic review, meta-analysis and qualitative analysis

Background

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy of the upper limb. Treatment options include physiotherapy, splinting, steroid injections or surgery.

Objective

To compare the effectiveness of surgical versus conservative treatment for CTS for symptom and functional improvement and improvement of neurophysiological parameters.

Methods

Systematic searches of PubMed and EBSCO host were conducted to identify the studies published between 1990 and 2016, comparing any surgical treatment to any conservative treatment. Participants were adults with a diagnosis of CTS, with symptom duration ranging from 8 months to 3 years. A meta-analysis and a qualitative analysis were conducted to summarize the results of the included studies and establish any agreement between the two.

Results

A total of 15 studies were included in the study and 10 were included in the meta-analysis, involving 1787 wrists. The qualitative and quantitative analyses were consistent with the results of both indicating that surgical treatment leads to a greater improvement of symptoms at six months (mean difference: 0.52, 95%CI 0.27 to 0.78) and a greater improvement of neurophysiological parameters [distal motor latency (mean difference: 0.31, 95%CI 0.06 to 0.56), sensory nerve conduction velocity (mean difference: 3.71 m/s, 95%CI 1.94 to 5.49)]. At 3 months and 12 months, the results were not significant in favor of surgery or conservative treatment.

Conclusion

Conservative treatment for CTS should be preferred for mild and short-term CTS. Surgery is more effective than conservative in CTS, and should be considered in persisting symptoms, taking into account the complications, which are more severe after surgery. Further research should focus on the field of manual therapy and compare it to surgical treatment for CTS.

Effectiveness of surgical versus conservative treatment for carpal tunnel syndrome: A systematic review, meta-analysis and qualitative analysis

Background

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy of the upper limb. Treatment options include physiotherapy, splinting, steroid injections or surgery.

Objective

To compare the effectiveness of surgical versus conservative treatment for CTS for symptom and functional improvement and improvement of neurophysiological parameters.

Methods

Systematic searches of PubMed and EBSCO host were conducted to identify the studies published between 1990 and 2016, comparing any surgical treatment to any conservative treatment. Participants were adults with a diagnosis of CTS, with symptom duration ranging from 8 months to 3 years. A meta-analysis and a qualitative analysis were conducted to summarize the results of the included studies and establish any agreement between the two.

Results

A total of 15 studies were included in the study and 10 were included in the meta-analysis, involving 1787 wrists. The qualitative and quantitative analyses were consistent with the results of both indicating that surgical treatment leads to a greater improvement of symptoms at six months (mean difference: 0.52, 95%CI 0.27 to 0.78) and a greater improvement of neurophysiological parameters [distal motor latency (mean difference: 0.31, 95%CI 0.06 to 0.56), sensory nerve conduction velocity (mean difference: 3.71 m/s, 95%CI 1.94 to 5.49)]. At 3 months and 12 months, the results were not significant in favor of surgery or conservative treatment.

Conclusion

Conservative treatment for CTS should be preferred for mild and short-term CTS. Surgery is more effective than conservative in CTS, and should be considered in persisting symptoms, taking into account the complications, which are more severe after surgery. Further research should focus on the field of manual therapy and compare it to surgical treatment for CTS.

Are Passive Physical Modalities Effective for the Management of Common Soft Tissue Injuries of the Elbow?: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

OBJECTIVE

To evaluate the effectiveness of passive physical modalities for the management of soft tissue injuries of the elbow.

METHODS

We systematically searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials from 1990 to 2015. Studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. We included studies with a low risk of bias in our best evidence synthesis.

RESULTS

We screened 6618 articles; 21 were eligible for critical appraisal and 9 (reporting on 8 randomized controlled trials) had a low risk of bias. All randomized controlled trials with a low risk of bias focused on lateral epicondylitis. We found that adding transcutaneous electrical nerve stimulation to primary care does not improve the outcome of patients with lateral epicondylitis. We found inconclusive evidence for the effectiveness of: (1) an elbow brace for managing lateral epicondylitis of variable duration; and (2) shockwave therapy or low-level laser therapy for persistent lateral epicondylitis.

DISCUSSION

Our review suggests that transcutaneous electrical nerve stimulation provides no added benefit to patients with lateral epicondylitis. The effectiveness of an elbow brace, shockwave therapy, or low-level laser therapy for the treatment of lateral epicondylitis is inconclusive. We found little evidence to inform the use of passive physical modalities for the management of elbow soft tissue injuries.

Treatment of mild to moderate carpal tunnel syndrome in patients with diabetic neuropathy using low level laser therapy versus ultrasound controlled comparative study

AIM

The aim of the present study was to investigate and compare between Low Level Laser Therapy (LLLT) and Ultrasound (US) in treatment of Carpal Tunnel Syndrome (CTS) using the advantage of application of treatment directly over the transverse carpal ligament, as well as over the course of the median nerve in the forearm simultaneously.

DESIGN

Fifty patients (25-55 years) with diabetic neuropathy, diagnosed as unilateral carpal tunnel syndrome participated in the study. They were equally divided and randomly assigned into two groups; each group consisted of 25 patients.

MATERIALS AND METHODS

Patients in group (A) received a program of IR Gallium Arsenide LLLT (wavelength 904 nm, average power 20 mW, laser probe 7 mm diameter), with a total application of 4.8 J, while patients in group (B) received a program of US (frequency 1 MHz, power 1.0 W/cm2, pulsed mode 1:5).

RESULTS & DISCUSSION

The results of our study showed that there were no statistical significance differences (P > 0.05) were observed between the two groups. It was concluded that both low level laser (20 mW power, 904 nm Wavelength) and ultrasound (1.0 w/cm2 power, 1 MHz frequency) are effective in the treatment of mild and moderate CTS patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Red LED photobiomodulation reduces pain hypersensitivity and improves sensorimotor function following mild T10 hemicontusion spinal cord injury

Background

The development of hypersensitivity following spinal cord injury can result in incurable persistent neuropathic pain. Our objective was to examine the effect of red light therapy on the development of hypersensitivity and sensorimotor function, as well as on microglia/macrophage subpopulations following spinal cord injury.

Methods

Wistar rats were treated (or sham treated) daily for 30 min with an LED red (670 nm) light source (35 mW/cm²), transcutaneously applied to the dorsal surface, following a mild T10 hemicontusion injury (or sham injury). The development of hypersensitivity was assessed and sensorimotor function established using locomotor recovery and electrophysiology of dorsal column pathways. Immunohistochemistry and TUNEL were performed to examine cellular changes in the spinal cord.

Results

We demonstrate that red light penetrates through the entire rat spinal cord and significantly reduces signs of hypersensitivity following a mild T10 hemicontusion spinal cord injury. This is accompanied with improved dorsal column pathway functional integrity and locomotor recovery. The functional improvements were preceded by a significant reduction of dying (TUNEL⁺) cells and activated microglia/macrophages (ED1⁺) in the spinal cord. The remaining activated microglia/macrophages were predominantly of the anti-inflammatory/wound-healing subpopulation (Arginase1⁺ED1⁺) which were expressed early, and up to sevenfold greater than that found in sham-treated animals.

Conclusions

These findings demonstrate that a simple yet inexpensive treatment regime of red light reduces the development of hypersensitivity along with sensorimotor improvements following spinal cord injury and may therefore offer new hope for a currently treatment-resistant pain condition.

Doppler sonography for ulnar neuropathy at the elbow

INTRODUCTION

The aim of this study was to determine the value of Doppler sonography for evaluation of ulnar neuropathy at the elbow (UNE).

METHODS

A total of 102 patients with a clinical suspicion of UNE and 50 healthy controls were examined by Doppler and gray-scale sonography.

RESULTS

Intraneural vascularization was found in 31 (46.3%) of 67 patients with confirmed UNE and in 3 (6.0%) of 50 healthy controls. Combining gray-scale sonography measurement of nerve size and the presence of intraneural vascularization increased sensitivity by 3%, but decreased the specificity. Patients with intraneural vascularization had more severe disease than those without intraneural vascularization (P < 0.05). The variables obtained by Doppler sonography were associated with the severity of UNE (P < 0.05).

CONCLUSIONS

Doppler sonography is not helpful for diagnosing UNE but can be used to assess the severity of UNE. Muscle Nerve 54: 258-263, 2016.

Placebo-controlled investigation of low-level laser therapy to treat carpal tunnel syndrome

OBJECTIVE

This study investigated the short-term efficacy of low-level laser therapy (LLLT) in patients with mild to moderate carpal tunnel syndrome (CTS), lasting for <1 year.

METHODS

Seventy-nine patients with CTS were included in this double-blind, placebo-controlled study, and randomly divided in two treatment groups: Experimental group (EG), active laser group (40 patients); and control group (CG), placebo (sham) laser group (39 patients). A GaAlAs diode laser [780 nm, 30 mW continuous wave (CW), 0.785 cm(2), 38.2 mW/cm(2)] was applied in contact with four points perpendicularly to the skin over the carpal tunnel area for 90 sec per point (2.7 J, 3.4 J/cm(2)/point). Both groups were treated five times per week, once a day over 2 weeks, followed by 10 treatments every other day for 3 weeks, that is, for a total of 20 treatments. Clinical assessment, including visual analogue scale (VAS) pain rating, Tinel's sign, and median nerve conduction studies (NCSs) were evaluated before, and 3 weeks after, the last LLLT treatment.

RESULTS

Significant reduction in pain, reduction in the percentage of patients with a positive Tinel's sign, and shortening of sensory and motor latency time in the NCS examination was observed in the experimental LLLT group (but not in the control group).

CONCLUSIONS

This study has observed and documented the statistically significant short-term effects of LLLT on CTS patients in comparison with a placebo group. The results support this conclusion, especially if the LLLT is applied in the earlier stages of CTS, and with mild to moderate cases.

Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial

This randomized clinical trial investigated the effectiveness of surgery compared with physical therapy consisting of manual therapies including desensitization maneuvers in carpal tunnel syndrome (CTS). The setting was a public hospital and 2 physical therapy practices in Madrid, Spain. One hundred twenty women with CTS were enrolled between February 2013 and January 2014, with 1-year follow-up completed in January 2015. Interventions consisted of 3 sessions of manual therapies including desensitization maneuvers of the central nervous system (physical therapy group, n = 60) or decompression/release of the carpal tunnel (surgical group, n = 60). The primary outcome was pain intensity (mean pain and the worst pain), and secondary outcomes included functional status and symptoms severity subscales of the Boston Carpal Tunnel Questionnaire and the self-perceived improvement. They were assessed at baseline and 1, 3, 6, and 12 months by a blinded assessor. Analysis was by intention to treat. At 12 months, 111 (92%) women completed the follow-up (55/60 physical therapy, 56/60 surgery). Adjusted analyses showed an advantage (all, P < .01) for physical therapy at 1 and 3 months in mean pain (Δ -2.0 [95% confidence interval (CI) -2.8 to -1.2]/-1.3 [95% CI -2.1 to -.6]), the worst pain (Δ -2.9 [-4.0 to -2.0]/-2.0 [-3.0 to -.9]), and function (Δ -.8 [-1.0 to -.6]/-.3 [-.5 to -.1]), respectively. Changes in pain and function were similar between the groups at 6 and 12 months. The 2 groups had similar improvements in the symptoms severity subscale of the Boston Carpal Tunnel Questionnaire at all follow-ups. In women with CTS, physical therapy may result in similar outcomes on pain and function to surgery.

TRIAL REGISTRATION

http://www.clinicaltrials.gov, ClinicalTrials.gov, NCT01789645.

PERSPECTIVE

This study found that surgery and physical manual therapies including desensitization maneuvers of the central nervous system were similarly effective at medium-term and long-term follow-ups for improving pain and function but that physical therapy led to better outcomes in the short term.

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

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

Low-level laser therapy with a wrist splint to treat carpal tunnel syndrome: a double-blinded randomized controlled trial

The efficacy of low-level laser therapy (LLLT) was evaluated in a total of 66 patients with mild to moderate carpal tunnel syndrome (CTS) with a double-blinded randomized controlled study. The patients were randomly assigned into two groups. Group I received 15 sessions of a gallium-aluminum-arsenide laser treatment at a dosage of 18 J per session over the carpal tunnel area with neutral wrist splint. Group II received placebo laser therapy with neutral wrist splint. The patients were evaluated with the following parameters: (1) clinical parameters which consisted of visual analog scale, symptom severity scale, functional status scale, and pinch strength and grip strength before the treatment and at 5- and 12-week follow-ups and (2) electroneurophysiological parameters from nerve conduction study which were evaluated before the treatment and at 12-week follow-up. Fifty nine patients (112 hands: unilateral CTS = 6 hands and bilateral CTS = 106 hands) completed the study. Both groups I and II had n = 56 hands. Improvements were significantly more pronounced in the LLLT-treated group than the placebo group especially for grip strength at 5- and 12-week follow-ups. At 12-week follow-up, distal motor latency of the median nerve was significantly improved in the LLLT group than the placebo group (p < 0.05). LLLT therapy, as an alternative for a conservative treatment, is effective for treating mild to moderate CTS patients. It can improve hand grip strength and electroneurophysiological parameter with a carry-over effect up to 3 months after treatment for grip strength of the affected hands.

Ultrasonic assessment of females with carpal tunnel syndrome proved by nerve conduction study

INTRODUCTION

Carpal tunnel syndrome (CTS) is the most commonly diagnosed entrapment neuropathy of the upper extremity. The objective of this study was to diagnose CTS and to assess its severity using high resolution ultrasound (HRUS) depending on the results of nerve conduction study (NCS).

METHODS

A prospective cross-sectional study, in which HRUS was performed at 63 wrists of 35 female patients with different severity of CTS (as proved by NCS). Furthermore, 40 healthy volunteers (80 wrists) underwent the same tests as the patients and have been chosen to match the patients in gender, age, and body mass index (BMI). The cross section area (CSA) of the median nerve (MN) was obtained using HRUS at the carpal tunnel inlet by direct tracing method.

RESULTS

There was a significant difference in the CSA of the MN at the tunnel inlet in CTS patients when compared with the control group. In fact, the CSA of the control group showed a significant difference from each of patients subgroups. Furthermore, a significant difference in the CSA was seen in between these subgroups. In conclusion, the US examination of the MN seems to be a promising method in diagnosing and grading of carpal tunnel syndrome.

Low-level laser therapy alleviates neuropathic pain and promotes function recovery in rats with chronic constriction injury: possible involvements in hypoxia-inducible factor 1α (HIF-1α)

Nerve inflammation plays an important role in the development and progression of neuropathic pain after chronic constrictive injury (CCI). Recent studies have indicated that hypoxia-inducible factor 1α (HIF-1α) is crucial in inflammation. Low-level laser therapy has been used in treating musculoskeletal pain, but rare data directly support its use for neuropathic pain. We investigated the effects of low-level laser on the accumulation of HIF-1α, tumor necrosis factor-α (TNF-α), and interleukin-1β (IL-1β) in controlling neuropathic pain, as well as on the activation of vascular endothelial growth factor (VEGF) and nerve growth factor (NGF) in promoting functional recovery in a rat CCI model. CCI was induced by placing four loose ligatures around the sciatic nerve of rats. Treatments of low-level laser (660 nm, 9 J/cm(2)) or sham irradiation (0 J/cm(2)) were performed at the CCI sites for 7 consecutive days. The effects of laser in animals with CCI were determined by measuring the mechanical paw withdrawal threshold, as well as the sciatic, tibial, and peroneal function indices. Histopathological and immunoassay analyses were also performed. Low-level laser therapy significantly improved paw withdrawal threshold and the sciatic, tibial, and peroneal functional indices after CCI. The therapy also significantly reduced the overexpressions of HIF-1α, TNF-α, and IL-1β, and increased the amounts of VEGF, NGF, and S100 proteins. In conclusion, a low-level laser could modulate HIF-1α activity. Moreover, it may also be used as a novel and clinically applicable therapeutic approach for the improvement of tissue hypoxia/ischemia and inflammation in nerve entrapment neuropathy, as well as for the promotion of nerve regeneration. These findings might lead to a sufficient morphological and functional recovery of the peripheral nerve.

Comparison of the long-term effectiveness of physiotherapy programs with low-level laser therapy and pulsed magnetic field in patients with carpal tunnel syndrome

PURPOSE

The aim of the study was to compare the long term effects of low - level laser therapy (LLLT) and pulsed magnetic field (PMF) in the rehabilitation of patients with carpal tunnel syndrome (CTS).

METHODS

The study included 38 patients with idiopathic CTS, confirmed by electroneurographic (ENG) examination. All patients were randomly assigned to 2 groups: group L (18 patients) treated with LLLT and group M (20 patients) with PMF therapy. Clinical assessment, including day and night pain, the presence of paresthesia, functional tests (Phalen, Tinel, armband tests) and pain severity according to the Visual Analogue Scale (VAS) was conducted before treatment, after the first series of 10 sessions, after a two-week break, after the second series of 10 sessions and six months after the last series.

RESULTS

After LLLT a significant reduction of day and night pain was observed at each stage of treatment and 6 months after the last series (p<0.05). However, in group M, a significant reduction of both day and night pain was demonstrated only after the second series (p<0.05). A reduction of the incidence of Phalen's symptoms were noticed in both groups, however, only in group L the improvement was significant (p<0.05). In groups L and M a significant reduction of pain intensity was observed at every stage of treatment (p<0.05).

CONCLUSIONS

Although after LLL as well as PMF therapy clinical improvement was observed, the most significant differences were registered after the second series and persisted for up to 6 months in both groups.

LOW-LEVEL LASER THERAPY AFTER CARPAL TUNNEL RELEASE

OBJECTIVE

Evaluate the post-operative treatment of CTS, using the LLLT.

METHOD

We prospectively evaluated 58 patients with CTS, randomly divided into two groups: treatment with LLLT (Group 1) and placebo (Group 2). A 830 nm gallium-aluminum-arsenic laser was used, with a power of 30 mW.

RESULTS

There was female predominance in both groups. The mean age of the patients in Group 1 was 44.3 years and in Group 2, 51.9 years. The average duration of disease progression was around two years in both groups. The average time elapsed since discharge from treatment was 3.6 months in both groups, and fewer patients had postoperative complaints in Group 1 than in Group 2. At the end of the treatment, in Group 1, 29.41% of the patients presented electromyographic abnormalities, while in Group 2, 63.64% of the patients had abnormalities, after six months.

CONCLUSION

This was an initial study on adjuvant therapy using postoperative LLLT on CTS. The method presented was sufficient for postoperative evaluation of the patients in this study. Patients undergoing LLLT after surgery for CTS were benefited and had better functional outcomes than shown by the control group. The technique was effective and did not have any adverse effects on the patients studied.

Is surgical intervention more effective than non-surgical treatment for carpal tunnel syndrome? A systematic review

Background

Carpal tunnel syndrome is a common disorder in hand surgery practice. Both surgical and conservative interventions are utilized for the carpal tunnel syndrome. Although certain indications would specifically indicate the need for surgery, there is a spectrum of patients for whom either treatment option might be selected. The purpose of this systematic review was to compare the efficacy of surgical treatment of carpal tunnel syndrome with conservative treatment

Methods

We included all controlled trials written in English, attempting to compare any surgical interventions with any conservative therapies. We searched Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2010), MEDLINE (1980 to June 2010), EMBASE (1980 to June 2010), PEDro (searched in June 2010), international guidelines, computer searches based on key words and reference lists of articles. Two reviewers performed study selection, assessment of methodological quality and data extraction independently of each other. Weighted mean differences and 95% confidence intervals for patient self-reported functional and symptom questionnaires were calculated. Relative risk (RR) and 95% confidence intervals for electrophysiological studies and complication were also calculated.

Results

We assessed seven studies in this review including 5 RCTs and 2 controlled trials. The methodological quality of the trials ranged from moderate to high. The weighted mean difference demonstrated a larger treatment benefit for surgical intervention compared to non surgical intervention at six months for functional status 0.35( 95% CI 0.22, 0.47) and symptom severity 0.43 (95% CI 0.29, 0.57). There were no statistically significant difference between the intervention options at 3 months but there was a benefit in favor of surgery in terms of function and symptom relief at 12 months ( 0.35, 95% CI 0.15, 0.55 and 0.37, 95% CI 0.19 to 0.56). The RR for secondary outcomes of normal nerve conduction studies was 2.3 (95% CI 1.2, 4.4), while RR was 2.03 (95% CI 1.28 to 3.22) for complication, both favoring surgery.

Conclusion

Both surgical and conservative interventions had treatment benefit in carpal tunnel syndrome. Surgical treatment has a superior benefit, in symptoms and function, at six and twelve months. Patient underwent surgical release were two times more likely to have normal nerve conduction studies but also had complication and side effects as well. Given the treatment differential and potential for adverse effects and that conservative interventions benefitted a substantial proportion of patients, current practice of a trial of conservative management with surgical release for severe or persistent symptoms is supported by evidence.

Low-level laser in the treatment of carpal tunnel syndrome: clinical, electrophysiological, and ultrasonographical evaluation

The objective of this study is to investigate the efficacy of low-level laser therapy (LLLT) in patients with carpal tunnel syndrome (CTS). Sixty patients with CTS were included in this placebo-controlled and double-blind study and randomly assigned to three treatment groups: active laser with a dosage of 1.2 J/per painful point, active laser with a dosage of 0.6 J/per painful point, and placebo groups. A total of 5 points across the median nerve trace were irradiated with Gal-Al-As diode laser. All groups were treated 5 times per week for 3 weeks. Clinical assessments included pain intensity, grip strength, symptom severity score (SSS), functional status score (FSS), nerve conduction studies, and cross-sectional area (CSA) of the median nerve as measured by ultrasonography. Compared to baseline, post-treatment VAS scores (group 1, P < 0.001; group 2, P < 0.001; group 3, P < 0.01), grip strength (P < 0.05), SSS scores (group 1, P < 0.001; group 2, P < 0.001; group 3, P < 0.01), and FSS scores (P < 0.05) improved significantly in all groups. Only sensorial nerve velocity measurements on the palmar region showed a significant improvement in both active laser groups (P < 0.01). There was no significant difference in any of the outcome measures among the groups. With the chosen laser type and dose regimen, the results suggested that LLLT was no more effective than placebo in CTS.

Value of power Doppler and gray-scale US in the diagnosis of carpal tunnel syndrome: contribution of cross-sectional area just before the tunnel inlet as compared with the cross-sectional area at the tunnel

Objective

To determine the value of gray-scale and power Doppler ultrasonography in the evaluation of carpal tunnel syndrome (CTS).

Materials and Methods

Median nerves at the carpal tunnel were evaluated by using gray-scale and power Doppler ultrasonography and by using accepted and new criteria in 42 patients with CTS (62 wrists) confirmed by electromyogram and 33 control subjects. We evaluated the cross-sectional area of the nerve just proximal to the tunnel inlet (CSAa), and at mid level (CSAb). We then calculated the percentage area increase of CSAb, and area difference (CSAb-CSAa). We measured two dimensions of the nerve at the distal level to calculate the flattening ratio. The power Doppler ultrasonography was used to assess the number of vessels, which proceeded to give a score according to the vessel number, and lastly evaluated the statistical significance by comparing the means of patients with control subjects by the Student t test for independent samples. Sensitivities and specificities were determined for sonographic characteristics mentioned above. We obtained the receiver operating characteristic (ROC) curve to assess the optimal cut-off values for the diagnosis of CTS.

Results

A statistically significant difference was found between patients and the control group for mean CSAb, area difference, percentage area increase, and flattening ratio (p < 0.001, p < 0.001, p < 0.001, p < 0.05, respectively). From the ROC curve we obtained optimal cut-off values of 11 mm² for CSAb, 3.65 for area difference, 50% for the percentage of area increase, and 2.6 for the flattening ratio. The mean number of vessels obtained by power Doppler ultrasonography from the median nerve was 1.2. We could not detect vessels from healthy volunteers. Mean CSAbs related to vascularity intensity scores were as follows: score 0: 12.3 ± 2.8 mm², score 1: 12.3 ± 3.1 mm², score 2: 14.95 ± 3.5 mm², score 3: 19.3 ± 3.8 mm². The mean PI value in vessels of the median nerve was 4.1 ± 1.

Conclusion

Gray-scale and power Doppler ultrasonography are useful in the evaluation of CTS.

Current options for nonsurgical management of carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is the most common of the entrapment neuropathies. Surgical decompression is commonly performed and has traditionally been considered the defnitive treatment for CTS. Conservative treatment options include physical therapy, bracing, steroid injections and alternative medicine. While CTS is often progressive, patients may get better without formal treatment. The resolution of symptoms is not necessarily related to the severity of the clinical findings and self-limited activity is common. The current literature suggests that bracing and corticosteroid injections may be useful in the nonsurgical treatment of CTS, although the benefits may be short term. There is limited evidence regarding the efficacy of other treatments, such as therapy, exercise, yoga, acupuncture, lasers and magnets, and further studies are needed. Surgery is recommended for progressive functional deficits and significant pain.

Low-intensity light therapy: exploring the role of redox mechanisms

Low-intensity light therapy (LILT) appears to be working through newly recognized photoacceptor systems. The mitochondrial electron transport chain has been shown to be photosensitive to red and near-infrared (NIR) light. Although the underlying mechanisms have not yet been clearly elucidated, mitochondrial photostimulation has been shown to increase ATP production and cause transient increases in reactive oxygen species (ROS). In some cells, this process appears to participate in reduction/oxidation (redox) signaling. Redox mechanisms are known to be involved in cellular homeostasis and proliferative control. In plants, photostimulation of the analogous photosynthetic electron transport chain leads to redox signaling known to be integral to cellular function. In gene therapy research, ultraviolet lasers are being used to photostimulate cells through a process that also appears to involve redox signaling. It seems that visible and near visible low-intensity light can be used to modulate cellular physiology in some nonphotosynthetic cells, acting through existing redox mechanisms of cellular physiology. In this manner, LILT may act to promote proliferation and/or cellular homeostasis. Understanding the role of redox state and signaling in LILT may be useful in guiding future therapies, particularly in conditions associated with pro-oxidant conditions.

Surgical versus non-surgical treatment for carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome results from entrapment of the median nerve in the wrist. Common symptoms are tingling, numbness, and pain in the hand that may radiate to the forearm or shoulder. Most symptomatic cases are treated non-surgically.

OBJECTIVES

The objective is to compare the efficacy of surgical treatment of carpal tunnel syndrome with non-surgical treatment.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Trials Register (January 2008), MEDLINE (January 1966 to January 2008), EMBASE (January 1980 to January 2008) and LILACS (January 1982 to January 2008). We checked bibliographies in papers and contacted authors for information about other published or unpublished studies.

SELECTION CRITERIA

We included all randomised and quasi-randomised controlled trials comparing any surgical and any non-surgical therapies.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the eligibility of the trials.

MAIN RESULTS

In this update we found four randomised controlled trials involving 317 participants in total. Three of them including 295 participants, 148 allocated to surgery and 147 to non-surgical treatment reported information on our primary outcome (improvement at three months of follow-up). The pooled estimate favoured surgery (RR 1.23, 95% CI 1.04 to 1.46). Two trials including 245 participants described outcome at six month follow-up, also favouring surgery (RR 1.19, 95% CI 1.02 to 1.39).Two trials reported clinical improvement at one year follow-up. They included 198 patients favouring surgery (RR 1.27, 95% CI 1.05 to 1.53). The only trial describing changes in neurophysiological parameters in both groups also favoured surgery (RR 1.44, 95% CI 1.05 to 1.97). Two trials described need for surgery during follow-up, including 198 patients. The pooled estimate for this outcome indicates that a significant proportion of people treated medically will require surgery while the risk of re-operation in surgically treated people is low (RR 0.04 favouring surgery, 95% CI 0.01 to 0.17). Complications of surgery and medical treatment were described by two trials with 226 participants. Although the incidence of complications was high in both groups, they were significantly more common in the surgical arm (RR 1.38, 95% CI 1.08 to 1.76).

AUTHORS' CONCLUSIONS

Surgical treatment of carpal tunnel syndrome relieves symptoms significantly better than splinting. Further research is needed to discover whether this conclusion applies to people with mild symptoms and whether surgical treatment is better than steroid injection.