Non-operative Treatment of Carpal Tunnel Syndrome

Short-term clinical outcomes of mirogabalin for carpal tunnel syndrome: A single-center retrospective pilot study

Aims & objectives

Carpal tunnel syndrome (CTS) is a common condition caused by compression of the median nerve, leading to neuropathic pain such as numbness and nocturnal discomfort, thus impacting daily life. Mirogabalin besylate (MGB), a novel gabapentinoid, shows promise for neuropathic pain, but its efficacy in CTS remains unclear.Therefore, this pilot study aimed to evaluate the short-term clinical outcomes of MGB for CTS.

Materials & methods

This retrospective observational study examined 21 patients with CTS who received MGB between April 2022 and March 2023. Evaluations included the Carpal Tunnel Syndrome Instrument (CTSI), Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH), and Visual Analog Scale (VAS) before and 12 weeks after treatment. The primary outcome was the change in CTSI-total. Secondary outcomes included CTSI subparts (symptom severity and functional status), Quick DASH, VAS, and adverse drug reactions (ADRs).

Results

MGB led to significant improvement in CTSI-total (p=0.022), with medium standardized response mean (SRM) and effect size (ES). CTSI-symptom severity (p<0.01) and VAS (p<0.001) also improved, showing medium SRM and ES for CTSI and large SRM and ES for VAS. No significant changes were observed in CTSI-functional status (p=0.349) or Quick DASH (p=0.102). ADRs occurred in 42.9 % of patients, mostly mild.

Conclusions

MGB demonstrated significant short-term efficacy in improving CTS symptoms and reducing pain, though mild ADRs were common. Further studies are needed to assess long-term outcomes and compare MGB with other treatments.

Levels of evidence

Level IV.

Ultrasound-based grading of carpal tunnel syndrome: a comparative study of cross-sectional area and shear wave elastography at different wrist joint angles

OBJECTIVES

Carpal tunnel syndrome (CTS) is a prevalent neuropathy where accurate diagnosis is crucial for effective treatment planning. This study introduces a novel approach for CTS grading using ultrasound, specifically through the analysis of the cross-sectional area (CSA) and shear wave elastography (SWE) of the median nerve in various wrist positions.

METHODS

Our research involved subjects from outpatient clinics, diagnosed with CTS through nerve conduction studies (NCS), and a control group of healthy individuals. High-frequency ultrasound and SWE measurements were conducted in 3 wrist positions: straight, 45° extension, and 45° flexion.

RESULTS

The key findings revealed significant differences in median nerve CSA and SWE values between the CTS and control groups across all wrist positions, with notable variances in SWE values correlating with wrist positioning. SWE demonstrated enhanced sensitivity and specificity in distinguishing between mild, moderate, and severe CTS, especially at 45° wrist flexion. In contrast, CSA measurements were limited in differentiating between the varying severity stages of CTS.

CONCLUSIONS

The study concludes that SWE, particularly at 45° wrist flexion, provides a more precise diagnostic benchmark for CTS severity grading than CSA. This advancement in non-invasive diagnostic methodology not only aids in accurate CTS grading but also has significant implications in formulating tailored treatment strategies, potentially reducing the reliance on more invasive diagnostic methods like NCS.

ADVANCES IN KNOWLEDGE

This study marks a significant advancement in the ultrasound diagnosis of CTS. It particularly highlights the importance of applying SWE technology across various wrist joint angles, offering a new diagnostic benchmark. This discovery provides data support and additional insights for achieving an early consensus on ultrasound-based grading diagnosis of CTS.

Regional Variation in Carpal Tunnel Release Utilization, Reimbursement, Practice Styles, and Patient Populations: A Temporal Analysis

BACKGROUND

The purpose of this study was to evaluate changes in open carpal tunnel release (OCTR) and endoscopic carpal tunnel release (ECTR) utilization, reimbursement, and patient demographics in the Medicare population from 2013 to 2021 at national and regional levels.

MATERIALS AND METHODS

The Medicare Physician & Other Practitioners database from 2013 to 2021 was queried to extract all instances of OCTR and ECTR. Utilization per 10,000 beneficiaries, inflation-adjusted reimbursement, and patient characteristics were extracted for OCTR and ECTR each year. Data were stratified by region based on US Census guidelines. Kruskal-Wallis tests and multivariable linear regressions were performed.

RESULTS

From 2013 to 2021, national utilization per 10,000 beneficiaries increased by 6% for OCTR and by 50% for ECTR. In 2021, the Midwest had the greatest utilization of OCTR (29 of 10,000) and the lowest utilization of ECTR (7 of 10,000). Inflation-adjusted reimbursement declined for both OCTR and ECTR during the study period (10.3% and 11.8%, respectively), with the South having the lowest reimbursement for both procedures. The severity of patient comorbidity profiles and dual Medicare-Medicaid enrollees decreased for both procedures as well.

CONCLUSION

Both OCTR and ECTR utilization have increased, while inflation-adjusted reimbursement has decreased. Patient populations encompassed fewer dual Medicare-Medicaid enrollees, indicating surgeons may be more selective in operative indications. These findings should be addressed to ensure the economic sustainability of carpal tunnel release procedures and equitable access to quality hand care for all patients with Medicare. [Orthopedics. 2025;48(1):e45-e51.].

A Cost-Utility Analysis of Carpal Tunnel Release With Open, Endoscopic, and Ultrasound Guidance Techniques From a Societal Perspective

Purpose

The objective of this study was to perform a cost-utility analysis comparing open carpal tunnel release (OCTR), endoscopic carpal tunnel release (ECTR), and carpal tunnel release with ultrasound (CTR-US) guidance. The aim of this study was to determine whether one of the three approaches was dominant from a societal perspective in terms of cost-utility, in order to help inform policy and treatment decision making going forward.

Methods

This study was performed using a decision tree model, with three potential treatment decisions (OCTR, ECTR, and CTR-US). A cost-utility analysis was performed, using the incremental cost-effectiveness ratio. The willingness-to-pay threshold was set at $50,000/quality-adjusted life year (QALY) as per previous literature.

Results

The total payer episode costs for OCTR, ECTR, and CTR-US were $4,324, $4,978, and $3,249, respectively. The cost of time off work for each procedure was $4,376.14, $3,650.24, and $622.20, respectively. The overall QALYs gained from each procedure were 0.42, 0.42, and 0.43, respectively (the maximum possible being 0.5 for a 6-month period). Compared with OCTR, ECTR and CTR-US were both less costly from a societal perspective (-$71.90 and -$4,828.94, respectively) and associated with greater QALYs gained (+0.0004 and +0.0143, respectively).

Conclusions

Overall, the key finding of this study is that, from a societal perspective, CTR-US is less costly and provides greater QALY improvement when compared with OCTR and ECTR, and thus, CTR-US is considered a dominant intervention over both OCTR and ECTR.

Type of study/level of evidence

Economic and decision analysis; IIb.

Comparison of the Effects of Volar-Assisted and Elastic Wrist Splints on Edema, Pain, Grip Strength, and Functionality in Pregnant Women With Carpal Tunnel Syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is a common musculoskeletal problem in pregnancy. The aim of this study is to compare the effects of rigid and elastic wrist splints on edema, pain levels, grip strength, and upper-extremity functionality in pregnant women with CTS.

METHODS

Forty-one pregnant women in the last trimester of pregnancy who were diagnosed with CTS were included in the study. The grip strength was evaluated with the Jamar hand dynamometer, functionality with the Quick Disabilities of the Arm, Shoulder, and Hand and Boston Carpal Tunnel Syndrome Questionnaire, pain with the Visual Analog Scale (VAS), and edema with the water overflow method.

RESULTS

The mean age of the participants was 31.71 ± 5.78 years, body mass index was 28.85 ± 3.63 kg/m2, duration of pain was 2.24 ± 0.79 months, and their pain intensity was 6.63 ± 1.69 according to the VAS. As a result of the study, reductions in pain (P = .001), increases in functionality values (P = .001), increases in grip strength (P = .001), and decreases in edema (P = .001) were observed in both groups after the treatment. However, there was no significant difference in pain, functionality, or grip strength values between the groups after the treatment (P > .05).

CONCLUSION

In this study comparing the effects of a wrist splint to those of an elastic splint, both treatment methods for pregnant women with CTS decreased pain and edema, increased grip strength, and improved upper-extremity functionality. Considering individual needs, characteristics, and living conditions, both splints can be recommended for pregnant women with CTS.

The effects of virtual reality-mediated tendon and nerve gliding exercises in the conservative management of carpal tunnel syndrome: a double-blind randomized placebo controlled trial

BACKGROUND

Carpal tunnel syndrome (CTS) is a common condition resulting from compression of the median nerve at the wrist. First-line treatment typically involves conservative management, which commonly includes splinting and gliding exercises. Emerging evidence suggests the potential benefits of using virtual reality (VR) in rehabilitation.

AIM

This study aimed to assess the effects of VR-mediated tendon and nerve gliding exercises on the conservative treatment of CTS, compared to video-assisted (sham virtual) and home-based gliding exercises.

DESIGN

This study was a prospective, double-blind, randomized, placebo controlled interventional trial.

SETTING

The study was conducted in the Department of Physical Medicine and Rehabilitation at a university hospital.

POPULATION

The study included patients with mild to moderate CTS.

METHODS

The study included a total of 54 hands from 33 patients. The participants were randomly allocated into three groups: the VR-mediated group (VG), the sham VR-mediated group (SG), and the control (home-based) group (CG). Both intervention groups engaged in gliding exercises utilizing a Leap Motion Controller-based VR system and instructional videos, under the supervision of a physical therapist. The VR system was activated for the VG and deactivated for the SG. Exercises were performed twice weekly for eight weeks. The CG received a brochure describing the gliding exercises. Primary outcomes were symptom severity measured by the Numerical Rating Scale (NRS) and the Boston Carpal Tunnel Questionnaire (BCTQ), along with nerve conduction studies. Secondary outcomes included muscle strength (hand grip, key pinch), sensory measures (static two-point discrimination, vibration), and quality of life.

RESULTS

Both the VG and SG showed significant improvements in NRS and BCTQ scores compared to the CG in within-group comparisons. Nighttime symptoms improved significantly in the VG compared to the CG in between-group analyses. Electrophysiological findings showed no significant changes.

CONCLUSIONS

An eight-week VR-mediated exercise program may enhance tendon and nerve gliding exercise effectiveness, particularly for nighttime symptoms in CTS patients.

CLINICAL REHABILITATION IMPACT

In the future, challenging exercises requiring time and supervision could be effectively performed through VR, offering an alternative to traditional methods.

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.

Safety and Efficacy of Ultrasound-Guided Perineural Hydrodissection as a Minimally Invasive Treatment in Carpal Tunnel Syndrome: A Systematic Review

Ultrasound-guided perineural hydrodissection (HD) is a novel technique that has been found to be effective in providing mechanical release of perineural adhesions and decompression of the nerve, reducing inflammation and edema and restoring its physiological function. It has a significant impact on chronic neuropathic pain (20 ± 4 weeks with VAS < 5 or VAS diminished by 2 points after the procedure). Carpal tunnel syndrome (CTS) is a common entrapment mononeuropathy, and its distribution is typically innervated by the median nerve. Patients with mild or moderate CTS may benefit from nonsurgical treatments or conservative therapies. This review was conducted following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement guidelines. Four investigators assessed each title, abstract, and full-text article for eligibility, with disagreements being resolved by consensus with two experienced investigators. The qualitative assessment of the studies was carried out using the modified Oxford quality scoring system, also known as the modified Jadad score. Furthermore, risk of possible biases was assessed using the Cochrane collaboration tool. The results of this review suggest that US-guided HD is an innovative, effective, well-tolerated, and safe technique (11 out of 923 patients had collateral or side effects after the procedure). However, further studies comparing all drugs and with a larger sample population are required to determine the most effective substance.

Neuromodulation of the median nerve in carpal tunnel syndrome, a single-blind, randomized controlled study

Background

This study aimed to evaluate the efficacy of pulsed radiofrequency applied using transcutaneous electrodes in carpal tunnel syndrome (CTS).

Methods

After randomization, the patients received two cycles of noninvasive pulsed radiofrequency (NiPRF), once weekly, or splinting (the control group) for three months. Clinical evaluations were recorded at baseline and weeks 4 and 8. The Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) was used to determine the functional status and symptom severity.

Results

Sixty-two patients were followed up for three months. There was no difference between the groups in the BCTQ scores before and after treatment. The NiPRF group found a significant difference between the BCTQ measurements at all time intervals (paired sample t -test; P < 0.001). In the splint group, there was a significant difference only between the basal-1st month and basal-3rd month (paired samples t -test; P < 0.001). The main effect of the time variable was statistically significant (ANOVA; P < 0.001), but the group variable was not. There was no correlation between the BCTQ results measured at any time and the electroneuromyelogragphy findings in either group.

Conclusions

NiPRF effectively improves symptoms and functionality in patients with CTS for up to 3 months. Thus, NiPRF can be considered an easy, safe, and useful alternative treatment modality for CTS.

Efficacy of splinting the wrist and metacarpophalangeal joints for the treatment of Carpal tunnel syndrome: an assessor-blinded randomised controlled trial

OBJECTIVES

To compare the efficacy of a traditional cock-up splint, which supports the wrist only, with a modified splint that supports the wrist and the metacarpophalangeal (MCP) joints of the medial four digits in the treatment of carpal tunnel syndrome (CTS).

DESIGN

An assessor-blind randomised controlled trial.

SETTING

Hospital-based hand therapy clinics.

PARTICIPANTS

Fifty-nine adults with mild-to-moderate CTS were randomly assigned to wear a wrist splint (control group) or an MCP splint (intervention group) for 6 weeks.

OUTCOME MEASURES

The standardised outcome measures used included grip and pinch strength, the static two-point discrimination test, Phalen's manoeuvre test, Tinel's sign and the Boston CTS Questionnaire.

RESULTS

Both groups improved significantly from splint use in some clinical features. The wrist splint and the MCP splint groups had significant improvements in lateral pinch strength (p=0.032 and p=0.002, respectively), two-point discrimination of the thumb (p=0.003 and p=0.041, respectively), two-point discrimination of the index (p=0.035 and p=0.023, respectively) and the Phalen's manoeuvre symptoms (p=0.025 and p=0.002, respectively). The MCP splint group had additional improvements over the wrist splint group in tip pinch (p=0.012) and Palmar pinch (p=0.011) strength.

CONCLUSION

Splinting is a practical and effective intervention option for improving the symptoms of CTS. A wrist splint that incorporates the MCP joints is more effective than the traditional wrist-only splint, with long-lasting improvements that remained consistent after 6 months of the splint intervention. Using the more effective MCP splint may consequently reduce disability, facilitate return to work and lower the associated costs.

TRIAL REGISTRATION NUMBER

ISRCTN13189602.

The effectiveness of mobilization with movement on patients with mild and moderate carpal tunnel syndrome: A single-blinded, randomized controlled study

STUDY DESIGN

Single-blinded, randomized controlled study.

INTRODUCTION

Carpal Tunnel Syndrome (CTS) causes pain and loss of function in the affected hand. The mobilization with movement (MWM) technique is a manual therapy method applied to correct joint movement limitation and to relieve pain and functional disorders.

PURPOSE OF THE STUDY

This study aimed to examine the effectiveness of MWM technique on pain, grip strength, range of motion, edema, hand reaction, nerve conduction, and functional status in patients with CTS.

METHODS

A total of 45 patients enrolled in the study. The MWM group (n = 18) completed a 4-week combined conservative physiotherapy and MWM program, whereas the control group (n = 18) received only the 4 weeks of conservative physiotherapy. Pain severity according to the numerical rating scale was used as primary outcome.

RESULTS

We found an improvement within the subjects in resting pain (MWMG:5.1 ± 3.6 vs 1.1 ± 2.4, Effect Size (ES)=1.3; CG:4.5 ± 3.3 vs 1.0 ± 2.2, ES=1.1), in activity pain (MWMG:6.5 ± 3.7 vs 1.1 ± 2.4, ES=1.5; CG:4.8 ± 3.4 vs 2.2 ± 2.3, ES=1) and in night pain (MWMG:5.9 ± 3.2 vs 1.8 ± 2.5, ES=1.2; CG:5.3 ± 4.2 vs ± 2.3 ± 3.5, ES=0.9). For between the groups, a statistical difference was found for the activity pain, Disabilities of the Arm Shoulder and Hand Questionnaire score (MWMG:52.2 ± 23.8 vs 27 ± 24.7, ES=1.3; CG:47.0 ± 24.8 vs 41.5 ± 22.1, ES=0.2), Michigan Hand Outcomes Questionnaire (MHQ-1), (MWMG:44.4 ± 23.7 vs 74.7 ± 24.5, ES=1.3; CG:44.8 ± 17.4 vs 57.4 ± 21.7, ES=0.9) and MHQ-5 (MWMG:68.8 ± 13.1 vs 82.5 ± 11.5, ES=0.9; CG:63.4 ± 26.7 vs 59.3 ± 25.8, ES=0.1) parameters in favour of MWM group.

DISCUSSION

This study showed that MWM compared to conservative physiotherapy might be more effective in reducing perceived symptoms in mild and moderate CTS patients.

CONCLUSIONS

MWM produced a small benefit to recovery of activity pain and upper extremity functionality level outcomes of patients with mild to moderate CTS when added to a traditional CTS physical therapy program.

Vasculitis presenting as carpal tunnel syndrome: a case report

BACKGROUND

Carpal tunnel syndrome is the most common focal mononeuropathy which presents with pain in the wrist and hand, paresthesia, loss of sensation in the distribution of the median nerve, and in more severe cases, weakness and atrophy of the thenar muscles. Meanwhile, carpal tunnel syndrome can present as an initial manifestation of underlying systemic vasculitis disorder and result in severe physical disabilities.

CASE PRESENTATION

A 27-year-old Iranian man was referred to our electrodiagnosis center with a clinical diagnosis of carpal tunnel syndrome in April 2020. Surgical intervention had been taken into account for him because of unsuccessful conservative therapies. On admission, thenar eminence was reduced. Electrodiagnostic findings were not compatible with median nerve entrapment at the wrist. All sensory modalities in the distribution of the right median nerve were decreased. Additionally, a mild increase in erythrocyte sedimentation rate was noted in laboratory tests. Because of the high vasculitis suspicion, we recommended the nerve biopsy and/or starting a high-dose corticosteroid. However, the surgery release was performed. After 6 months, the patient was referred for progressive weakness and numbness in the upper and lower limbs. After documentation of vasculitis neuropathy by biopsy, a diagnosis of non-systemic vasculitic neuropathy was confirmed. A rehabilitation program started immediately. Rehabilitation led to gradual improvement and recovery of function and muscle strength, and no complications remained, except mild leg paralysis.

CONCLUSIONS

Physicians should be suspicious of the median nerve vasculitis mononeuropathy in a patient with carpal tunnel syndrome-like symptoms. Median nerve vasculitis mononeuropathy as an initial presenting feature of vasculitis neuropathy can further result in severe physical impairments and disabilities.

Injections for treatment of carpal tunnel syndrome: A narrative review of the literature

Background

Carpal tunnel syndrome is an extremely common condition in the general population. Nonoperative treatment is a mainstay of management prior to surgical carpal tunnel release. Injections are frequently used as treatment, especially corticosteroid injections, but there is little consensus in the literature regarding injection number, volume, corticosteroid dose, and technique.

Methods

A comprehensive literature search was performed of PubMed to identify papers relating to corticosteroid injections as well as other injections performed in patients with carpal tunnel syndrome.

Results

A total of 45 articles were selected for inclusion in this review. Corticosteroid injections for carpal tunnel syndrome are discussed in detail, including injection number, volume, and technique as well as corticosteroid dose. Alternative injections for management of carpal tunnel syndrome are also discussed.

Conclusions

Corticosteroid injections have been identified as a safe, effective short term management option for carpal tunnel syndrome. However, there is no standardized recommendation for specifics of their use in relation to corticosteroid dose, number of injections, injectate volume, and use of ultrasound guidance. Further research is required to better establish the optimal role for corticosteroid injections in the treatment of carpal tunnel syndrome. Platelet rich plasma, lidocaine, and hyaluronic acid, among others, are additional injections that warrant further exploration for use in management of carpal tunnel syndrome.

Splinting for carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is a compression neuropathy of the median nerve causing pain and numbness and tingling typically in the thumb, index and middle finger. It sometimes results in muscle wasting, diminished sensitivity and loss of dexterity. Splinting the wrist (with or without the hand) using an orthosis is usually offered to people with mild-to-moderate findings, but its effectiveness remains unclear.

OBJECTIVES

To assess the effects (benefits and harms) of splinting for people with CTS.

SEARCH METHODS

On 12 December 2021, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, AMED, CINAHL, ClinicalTrials.gov, and WHO ICTRP with no limitations. We checked the reference lists of included studies and relevant systematic reviews for studies.

SELECTION CRITERIA

Randomised trials were included if the effect of splinting could be isolated from other treatment modalities. The comparisons included splinting versus no active treatment (or placebo), splinting versus another disease-modifying non-surgical treatment, and comparisons of different splint-wearing regimens. We excluded studies comparing splinting with surgery or one splint design with another. We excluded participants if they had previously undergone surgical release.

DATA COLLECTION AND ANALYSIS

Review authors independently selected trials for inclusion, extracted data, assessed study risk of bias and the certainty in the body of evidence for primary outcomes using the GRADE approach, according to standard Cochrane methodology.

MAIN RESULTS

We included 29 trials randomising 1937 adults with CTS. The trials ranged from 21 to 234 participants, with mean ages between 42 and 60 years. The mean duration of CTS symptoms was seven weeks to five years. Eight studies with 523 hands compared splinting with no active intervention (no treatment, sham-kinesiology tape or sham-laser); 20 studies compared splinting (or splinting delivered along with another non-surgical intervention) with another non-surgical intervention; and three studies compared different splinting regimens (e.g. night-time only versus full time). Trials were generally at high risk of bias for one or more domains, including lack of blinding (all included studies) and lack of information about randomisation or allocation concealment in 23 studies. For the primary comparison, splinting compared to no active treatment, splinting may provide little or no benefits in symptoms in the short term (< 3 months). The mean Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (SSS) (scale 1 to 5, higher is worse; minimal clinically important difference (MCID) 1 point) was 0.37 points better with splint (95% confidence interval (CI) 0.82 better to 0.08 worse; 6 studies, 306 participants; low-certainty evidence) compared with no active treatment. Removing studies with high or unclear risk of bias due to lack of randomisation or allocation concealment supported our conclusion of no important effect (mean difference (MD) 0.01 points worse with splint; 95% CI 0.20 better to 0.22 worse; 3 studies, 124 participants). In the long term (> 3 months), we are uncertain about the effect of splinting on symptoms (mean BCTQ SSS 0.64 better with splinting; 95% CI 1.2 better to 0.08 better; 2 studies, 144 participants; very low-certainty evidence). Splinting probably does not improve hand function in the short term and may not improve hand function in the long term. In the short term, the mean BCTQ Functional Status Scale (FSS) (1 to 5, higher is worse; MCID 0.7 points) was 0.24 points better (95% CI 0.44 better to 0.03 better; 6 studies, 306 participants; moderate-certainty evidence) with splinting compared with no active treatment. In the long term, the mean BCTQ FSS was 0.25 points better (95% CI 0.68 better to 0.18 worse; 1 study, 34 participants; low-certainty evidence) with splinting compared with no active treatment. Night-time splinting may result in a higher rate of overall improvement in the short term (risk ratio (RR) 3.86, 95% CI 2.29 to 6.51; 1 study, 80 participants; number needed to treat for an additional beneficial outcome (NNTB) 2, 95% CI 2 to 2; low-certainty evidence).  We are uncertain if splinting decreases referral to surgery, RR 0.47 (95% CI 0.14 to 1.58; 3 studies, 243 participants; very low-certainty evidence).  None of the trials reported health-related quality of life. Low-certainty evidence from one study suggests that splinting may have a higher rate of adverse events, which were transient, but the 95% CIs included no effect. Seven of 40 participants (18%) reported adverse effects in the splinting group and 0 of 40 participants (0%) in the no active treatment group (RR 15.0, 95% CI 0.89 to 254.13; 1 study, 80 participants).  There was low- to moderate-certainty evidence for the other comparisons: splinting may not provide additional benefits in symptoms or hand function when given together with corticosteroid injection (moderate-certainty evidence) or with rehabilitation (low-certainty evidence); nor when compared with corticosteroid (injection or oral; low certainty), exercises (low certainty), kinesiology taping (low certainty), rigid taping (low certainty), platelet-rich plasma (moderate certainty), or extracorporeal shock wave treatment (moderate certainty). Splinting for 12 weeks may not be better than six weeks, but six months of splinting may be better than six weeks of splinting in improving symptoms and function (low-certainty evidence).

AUTHORS' CONCLUSIONS

There is insufficient evidence to conclude whether splinting benefits people with CTS. Limited evidence does not exclude small improvements in CTS symptoms and hand function, but they may not be clinically important, and the clinical relevance of small differences with splinting is unclear. Low-certainty evidence suggests that people may have a greater chance of experiencing overall improvement with night-time splints than no treatment. As splinting is a relatively inexpensive intervention with no plausible long-term harms, small effects could justify its use, particularly when patients are not interested in having surgery or injections. It is unclear if a splint is optimally worn full time or at night-time only and whether long-term use is better than short-term use, but low-certainty evidence suggests that the benefits may manifest in the long term.

Pathophysiology, Diagnosis, Treatment, and Genetics of Carpal Tunnel Syndrome: A Review

Carpal tunnel syndrome (CTS) is a common peripheral canalicular nerve entrapment syndrome in the upper extremities. The compression of or injury to the median nerve at the wrist as it passes through a space-limited osteofibrous carpal canal can cause CTS, resulting in hand pain and impaired function. The present paper reviews the literature on the prevalence, pathology, diagnosis, treatment, and risk factors of CTS in conjunction with the role of genetic factors in CTS etiology. CTS diagnosis is primarily linked with clinical symptoms; still, it is simplified by sophisticated approaches such as magnetic resonance imaging and ultrasonography. CTS symptoms can be ameliorated through conservative and surgical strategies. The exact CTS pathophysiology needs clarification. Genetic predispositions to CTS are augmented by various variants within genes; however, CTS etiology could include risk factors such as wrist movements, injury, and specific conditions (e.g., age, body mass index, sex, and cardiovascular conditions). The high prevalence of CTS diminishes the quality of life of its sufferers and imposes costs on health systems, hence the significance of research and clinical trials to elucidate CTS pathogenesis and develop novel therapeutic targets.

Carpal Tunnel Syndrome: Pathophysiology and Comprehensive Guidelines for Clinical Evaluation and Treatment

In carpal tunnel syndrome (CTS), the median nerve is compressed at the level of the carpal tunnel in the wrist. This entrapment manifests as unpleasant symptoms, such as burning, tingling, or numbness in the palm that extends to the fingers. As the disease progresses, afflicted individuals also report decreased grip strength accompanied by hand weakness and restricted movement. The first half of this review elaborates on CTS pathology by providing readers with a comprehensive understanding of the etiology, relevant anatomy, and disease mechanism. CTS is considered the most common entrapment neuropathy, affecting around 3-6% of the adult population. Further, CTS prevalence has seen a dramatic increase in the last few decades paralleling the growth of everyday technology usage. Despite how common it is to have CTS, it can be quite challenging for physicians to make a definite diagnosis due to differentials that present with overlapping symptoms. Even more difficult can be deciding on a course of treatment that is the most effective and considerate of patient needs. Thus arises the need for clear clinical direction, and hence we end with a discussion around such guidelines that serve as a starting point toward effective diagnoses and patient treatment.

Nerve Imaging in the Wrist

Neuropathic symptoms involving the wrist are a common clinical presentation that can be due to a variety of causes. Imaging plays a key role in differentiating distal nerve lesions in the wrist from more proximal nerve abnormalities such as a cervical radiculopathy or brachial plexopathy. Imaging complements electrodiagnostic testing by helping define the specific lesion site and by providing anatomical information to guide surgical planning. This article reviews nerve anatomy, normal and abnormal findings on ultrasonography and magnetic resonance imaging, and common and uncommon causes of neuropathy.

Effectiveness of Platelet-Rich Plasma for Patients With Carpal Tunnel Syndrome: A Systematic Review and meta-Analysis of Current Evidence in Randomized Controlled Trials

Background: Recently, there was a series of clinical studies focusing on local injection of platelet-rich plasma (PRP) for treatment of patients with carpal tunnel syndrome (CTS). However, the safety and efficacy of PRP in these CTS patients remains controversial. Therefore, we performed a systematic review to compare PRP with other conservative treatments in treatment of CTS patients.

Methods: We systematically searched from electronic databases (Cochrane, PubMed, Web of Science, and EMBASE) up to 10 December 2021. The data of clinical results were extracted and analyzed by RevMan Manager 5.4.

Results: Finally, eight randomized controlled studies, involving 220 CTS patients undergoing local injection of PRP were enrolled in this systematic review. All enrolled trials were considered to be of high quality. In the short-term efficacy, the PRP group was significantly lower in symptom severity scale (SSS) compared with the control group (MD = −2.00; 95% CI, −3.15 to −0.85; p = 0.0007; I² = 0%). In the mid-term efficacy, the PRP group was significantly effective than the control group in the visual analogue scale (MD = −0.63; 95% CI, −1.22 to −0.04; p = 0.04; I² = 61%), SSS (MD = −3.56; 95% CI, −4.93 to −2.18; p < 0.00001; I² = 0%), functional status scale (MD = −2.29; 95% CI, −3.03 to −1.56; p < 0.00001; I² = 45%), sensory peak latency (MD = −0.39; 95% CI, −0.58 to −0.19; p = 0.0001; I² = 0%) and cross-sectional area of median nerve (MD = -0.20; 95% CI, −0.31 to −0.10; p = 0.0002; I² = 0%). In the mid-long-term efficacy, the PRP group was only significantly lower in SSS compared with the control group (MD = −2.71; 95% CI, −4.33 to −1.10; p = 0.001; I² = 38%).

Conclusion: Local PRP injection is more effective than other conservative treatments in terms of mid-term efficacy in relieving pain, improving wrist function and symptoms, reducing MN swelling, and partially improving electrophysiological indicators. However, the long-term adverse side and consensus on standardization of PRP in CTS patients still need further large-scale trials.

Physical therapy versus radial extracorporeal shock wave therapy in the treatment of carpal tunnel syndrome: A randomized-controlled study

Objectives: This study aims to compare the efficacy of physical therapy (PT) and radial extracorporeal shock wave therapy (rESWT) in the treatment of carpal tunnel syndrome (CTS).

Patients and methods: Between May 2020 and July 2020, a total of 125 wrists of 95 patients (22 males, 73 females; mean age: 54.3±11.3 years; range, 19 to 69 years) with mild-to-moderate CTS were allocated into three groups and evaluated. The control group (Group 1, n=42) was treated with splinting and an exercise program. Group 2 (n=42) was treated with a total of three sessions of rESWT, splinting and an exercise program. Group 3 (n=41) was treated with a total of 15 sessions of PT modalities, splinting, and an exercise program. Each patient was evaluated before, three weeks and 12 weeks after treatment using a Visual Analog Scale (VAS), the Boston Carpal Tunnel Questionnaire (BCTQ), the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Pain Scale, and electrodiagnostic testing.

Results: The reduction in VAS, BCTQ, LANSS, and improvement in sensory nerve conduction velocity were significantly greater at three and 12 weeks of follow-up in Groups 2 and 3, compared to Group 1 (p<0.001). A greater improvement was observed in all clinical parameters in Group 2, compared to Group 3 (p<0.001).

Conclusion: This is the first study to compare the treatment outcomes of PT and rESWT in the treatment of CTS. The results of this study show that both PT and rESWT are effective in the treatment of CTS; however, rESWT yields superior treatment effects compared to conventional PT. The practicalities of administering rESWT and its efficacy in the treatment of CTS may make it the treatment of choice.

Novel Motor-Sparing Ultrasound-Guided Neural Injection in Severe Carpal Tunnel Syndrome: A Comparison of Four Injectates

Nerve hydrodissection uses fluid injection under pressure to selectively separate nerves from areas of suspected entrapment; this procedure is increasingly viewed as potentially useful in treating carpal tunnel syndrome (CTS). The usage of normal saline (NS), 5% dextrose water (D5W), platelet-rich plasma (PRP), and hyaluronic acid (HA) as primary injectates for hydrodissection without an anesthetic can limit anesthetic-related toxicity and preserve the motor functions of the median nerve. Here, we describe a novel motor-sparing neural injection and compare the effect of these four injectates for severe CTS. We retrospectively reviewed the outcomes of 61 severe CTS cases after a single neural injection with NS, D5W, PRP, or HA. Outcomes were evaluated on the 1st and 6th months postinjection, including the Boston Carpal Tunnel Questionnaire (BCTQ) scores and the nerve cross-sectional area (CSA). The results revealed that PRP, D5W, and HA were more efficient than NS at all measured time points ( $p<0.05$ ), except for CSA at the 1st month between the NS and D5W groups. Single-injections of PRP and D5W seemed more effective than that of HA within 6 months postinjection for symptom and functional improvement (6th-month BCTQ-symptom, D5W vs. HA, $p=0.047$ ; 1st-month BCTQ-symptom, PRP vs. HA, $p=0.018$ ; 1st- and 6th-month BCTQ-function, D5W vs. HA, $p=0.002$ and 0.016, respectively; 1st-month BCTQ-function, PRP vs. HA, $p<0.001$ ). For reducing CSA, PRP and HA seemed more effective than D5W ( $\text{HA}>\text{PRP}>\text{D}5\text{W}$ on the 1st month and HA vs. D5W, $p=0.001$ ; $\text{PRP}>\text{HA}>\text{D}5\text{W}$ on the 6th month and PRP vs. D5W, $p=0.012$ ).

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).

The use of orthoses in the treatment of carpal tunnel syndrome. A review of the literature from the last 10 years

Introduction

A review of the literature from the last 10 years quite clearly shows that immobilization of the wrist in the splint (orthosis) is the most effective, initial method of conservative treatment of carpal tunnel syndrome (CTS). The particular advantages of the described method of treatment are: availability, low cost, good patient tolerance, simplicity and minimal incidence of complications.The aim of this study was to try to define the criteria of proceeding with the selection of the type of orthosis and the duration of its use depending on the clinical condition and the patient's expectations.

Methods

The PubMed electronic database was searched for appropriately selected studies published between 2012 and 2022. The search strategy used was based on the following keywords: carpal tunnel syndrome, immobilization, orthosis, conservative treatment. The authors also searched the cited literature on relevant research and review papers on potentially relevant topics related to conservative treatment of the CTS.

Conclusions

Immobilization in an orthosis gives therapeutic effects in all patients, regardless of the stage of the carpal tunnel syndrome.Most often the orthosis is only used at night for several weeks. During the exacerbation of symptoms, it can also be used during the day during activities that increase symptoms.In practice, it is recommended to wear a splint that immobilizes the wrist in a neutral position or slightly extended at 0-15 degrees (most often 0-5 degrees).A splint immobilizing the wrist and the 2-5 metacarpophalangeal joints are recommended for patients with positive Berger test results.There are no statistically significant differences in the treatment results between individual and traditional orthoses.No statistically significant differences were observed in the treatment effects between rigid and soft orthoses.

A Systematic Review of the Efficacy of Corticosteroid Injections of Tendon Sheaths, Excluding Stenosing Tenosynovitis of the Wrist and Hand

OBJECTIVE

Corticosteroid injections into tendon sheaths are common in clinical practice for treatment of a variety of tendon disorders. Previous systematic reviews have been performed on injections for stenosing tenosynovitis (DeQuervain tenosynovitis and trigger finger), but little high-level evidence remains for other tendon sheath injections. This systematic review analyzes the available literature on improvements in pain and function after these injections.

DESIGN

This systematic review of MEDLINE and Embase databases, as well as article bibliographies, examined studies of adult tendon sheath injections, excluding DeQuervain and trigger finger injections. Studies with and without comparison groups were examined. Risk of bias assessment was additionally performed.

RESULTS

Abstracts from 1293 records were screened, and 187 full-text articles were reviewed. Seven articles met final inclusion criteria, of which five were prospective trials and none were compared with a placebo. The proximal biceps, peroneal, finger flexor, and posterior tibialis tendons were explicitly examined. All articles reported at least short-term improvements in pain, and some reported improvement in function.

CONCLUSIONS

Low-quality studies exist that suggest tendon sheath injections may provide at least short-term improvement in pain. Controlled studies are required to fully demonstrate efficacy.