Ultrasound-guided corticosteroid injection for patients with carpal tunnel syndrome: a systematic review and meta-analysis of randomized controlled trials

Evolution and impact of a dedicated ultrasound clinic on clinical rheumatology practice at an academic medical center

BACKGROUND

Rheumatologic ultrasonography (RhUS) has grown in scope and application over the past 20 years. While many studies have shown the benefits of RhUS, few have investigated the efficacy of a dedicated clinic. This study explores the impact of a dedicated ultrasound clinic on patients and rheumatologists at an academic medical center (AMC).

METHODS

We analyzed claims data for patient visits, X-rays (XR), magnetic resonance imaging (MRI), and RhUS from an AMC with an established RhUS clinic, alongside two affiliated community medical practices (CMPs) without RhUS. We also analyzed RhUS clinic records on referral indication, procedures, results, and follow-up treatment changes. Pre- and post-RhUS visit patient surveys and referring physician (RP) surveys assessed experience and impact of the RhUS clinic.

RESULTS

From 2018 to 2021, referrals to the RhUS clinic substantially increased. In parallel, XR and MRI orders changed by -76 % and -43 % respectively, compared with 163 % and -24 % at CMPs. Discordance between RP pre-RhUS assessments and RhUS results were common. Patient surveys showed RhUS led to increased disease understanding and impacted thoughts and decisions about their therapy. RPs found utility in RhUS across a range of indications and were confident with RhUS results.

CONCLUSIONS

These findings suggest a dedicated RhUS clinic can be a valuable resource in clinical rheumatology practice. Implementation of a RhUS clinic at this AMC spurred rapid adoption of RhUS into clinical decision-making with notable benefits for patients and physicians alike. This may serve as a model for implementation of similar clinics at other institutions.

Application of a nerve stereoscopic reconstruction technique based on ultrasonic images in the diagnosis of neuralgic amyotrophy

Objective: To propose a nerve stereoscopic reconstruction technique based on ultrasound imaging for site diagnosis, intuitive reflection of disease severity, and classification of neuralgic amyotrophy (NA). Methods: We enrolled 44 patients with NA who underwent high-frequency ultrasonography examination. Multiple sites on the normal side and the affected side were scanned to calculate the ratio of the cross-section area (CSA) of the affected side to the normal side at each location measured, i.e., the cross-section area swelling ratio (CSASR). The CSASR of 44 patients and 30 normal controls was analyzed to determine their threshold value for the diagnosis of NA. Then, ultrasound images of the cross-section were used to reconstruct the stereoscopic model of the nerve on the affected side and the normal side. Using the CSASR values in each measurement location, a CSASR stereoscopic model was developed. Results: The threshold value of CSASR for ultrasound diagnosis of NA was 1.55. The average diseased segments per patient was 2.49 ± 1.97, with an average overall length of 10.03 ± 7.95 cm. Nerve stereoscopic reconstruction could be conducted for swelling, torsion, incomplete constriction, and complete constriction. Conclusion: The ultrasound image reconstruction method proposed in this study can accurately determine the site, range, and type of neuropathies in patients with NA, and simultaneously provide complete and accurate data information and intuitive morphological information.

Local injection therapy for carpal tunnel syndrome: a network meta-analysis of randomized controlled trial

Objective: Clinical research has shown that local injections for carpal tunnel syndrome reduce the symptoms of patients and enhance their quality of life considerably. However, there are several therapy options, and the optimal choice of regimen remains uncertain. Therefore, we comprehensively evaluated the variations in clinical efficacy and safety of several medications for treating carpal tunnel syndrome. Methods: Computer searches of Embase, PubMed, Cochrane Library, and Web of Science databases were used to collect articles of randomized controlled trials on local injections for treating carpal tunnel syndrome from database creation till 10 June 2023. Two researchers independently screened the literature, extracted information, evaluated the risk of bias in the included studies, and performed network Meta-analysis using Stata 17.0 software. Drug efficacy was assessed using symptom severity/function and pain intensity. Surface under the cumulative ranking curve (SUCRA) ranking was used to determine the advantage of each therapy. Results: We included 26 randomized controlled trials with 1896 wrists involving 12 interventions, such as local injections of corticosteroids, platelet-rich plasma, 5% dextrose, progesterone, and hyaluronidase. The results of the network meta-analysis showed the following: (i) symptom severity: at the 3-month follow-up, D5W combined with splinting (SUCRA = 95%) ranked first, and hyaluronidase (SUCRA = 89.6%) at 6 months; (ii) functional severity: either at the 3-month follow-up (SUCRA = 89.5%) or 6 months (SUCRA = 83.6%), iii) pain intensity: 5% dextrose in water combined with splinting was the most effective at the 3-month (SUCRA = 85%) and 6-month (SUCRA = 87.6%) follow-up. Conclusion: Considering the combination of symptoms/function and pain intensity, combining 5% dextrose in water with splinting is probably the treatment of choice for patients with carpal tunnel syndrome. It is more effective than glucocorticoids and no adverse effects have been observed. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022370525.

Carpal Tunnel Syndrome: Neuropathic Pain Associated or Not with a Nociplastic Condition

Carpal tunnel syndrome (CTS) has been traditionally classified as primarily a neuropathic condition with or without pain. Precision medicine refers to an evidence-based method of grouping patients based on their susceptibility to biology, prognosis of a particular disease, or in their response to a specific treatment, and tailoring specific treatments accordingly. In 2021, the International Association for the Study of Pain (IASP) proposed a grading system for classifying patients into nociceptive, neuropathic, or nociplastic phenotypes. This position paper presents data supporting the possibility of subgrouping individuals with specific CTS related-pain into nociceptive, neuropathic, nociplastic or mixed-type phenotypes. Carpal tunnel syndrome is a neuropathic condition but can also be comorbid with a nociplastic pain condition. The presence of extra-median symptoms and the development of facilitated pain processing seem to be signs suggesting that specific CTS cases can be classified as the nociplastic pain phenotype. The clinical responses of therapeutic approaches for the management of CTS are inconclusive. Accordingly, the ability to identify the predominant pain phenotype in patients with CTS could likely be problematic for producing efficient treatment outcomes. In fact, the presence of a nociplastic or mixed-type pain phenotype would explain the lack of clinical effect of treatment interventions targeting the carpal tunnel area selectively. We propose a clinical decision tree by using the 2021 IASP classification criteria for identifying the predominant pain phenotype in people with CTS-related pain, albeit CTS being a priori a neuropathic pain condition. The identification of a nociplastic-associated condition requires a more nuanced multimodal treatment approach to achieve better treatment outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Manual Therapy and Related Interventions for Carpal Tunnel Syndrome: A Systematic Review and Meta-Analysis

Objective: Systematic review and meta-analysis to assess the efficacy of Manual therapy and related interventions in the treatment of carpal tunnel syndrome (CTS) based on Boston carpal tunnel questionnaire. Design: Systematic review and meta-analysis. Subjects: Carpal tunnel syndrome. Interventions: Manual therapy and related interventions versus other therapies or manual therapy and related interventions plus other therapies versus other therapies. Outcomes measures: Boston carpal tunnel questionnaire. Results: A total of 6 studies were included, including 211 cases in the manual therapy group and 211 cases in the control group. The quality of the included articles was high, and the results of meta-analysis showed that manual therapy and related interventions were superior in terms of improving the Boston carpal tunnel questionnaire Symptom Severity score in patients with CTS (standardised mean difference [SMD] -1.13, 95% CI -1.40 to -0.87), were superior to control groups in terms of improving the Boston carpal tunnel questionnaire functional capacity scale in patients with CTS (SMD -1.01,95% CI -1.24 to -0.77). Conclusion: The results of this meta-analysis suggested that manual therapy and related interventions were better than control groups in treating CTS. Manual therapy and related interventions could relieve the symptoms of patients with CTS and promote the recovery of hand function. Manual therapy and related interventions should be considered clinically effective methods for treating CTS. Registration: The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; No. CRD 42020201389). Contribution of the Article: Manual therapy and related interventions could relieve the symptoms of patients with CTS and promote the recovery of hand function. Manual therapy and related interventions should be considered clinically effective methods for treating CTS.

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

Carpal tunnel syndrome is a neuropathic disease. It is one of the most frequent musculoskeletal pathologies affecting the upper limbs. One of most frequently used non-surgical treatments is corticosteorids. There are several alternatives for corticosteroids administration. One of them is phonophoresis, this being an effective and painless method of treatment. A systematic review and meta-analysis have been conducted over the use of phonophoresis with corticosteroids for the treatment of carpal tunnel syndrome compared to other non-surgical treatment methods. Keywords from Medical Subjects Headings (MeSH) were used in the following databases: Wos, Scopus, CINHAL, SciELO and PeDro. A total of 222 potentially relevant articles were retrieved. Eleven articles analysing the efficacy of phonophoresis with corticosteroids in reducing pain symptoms in individuals with carpal tunnel syndrome were included, 10 of which were used to conduct the meta-analysis. A conclusion could not be reached as to the application of phonophoresis with corticosteroids being better than other treatment methods, except for the perception of pain and an improved motor and sensory nerve conduction in cases of mild to moderate carpal tunnel syndrome.

Common Hand Conditions: A Review

Importance

Carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, and basilar (carpometacarpal) joint arthritis of the thumb can be associated with significant disability.

Observations

Carpal tunnel syndrome is characterized by numbness and tingling in the thumb and the index, middle, and radial ring fingers and by weakness of thumb opposition when severe. It is more common in women and people who are obese, have diabetes, and work in occupations involving use of keyboards, computer mouse, heavy machinery, or vibrating manual tools. The Durkan physical examination maneuver, consisting of firm digital pressure across the carpal tunnel to reproduce symptoms, is 64% sensitive and 83% specific for carpal tunnel syndrome. People with suspected proximal compression or other compressive neuropathies should undergo electrodiagnostic testing, which is approximately more than 80% sensitive and 95% specific for carpal tunnel syndrome. Splinting or steroid injection may temporarily relieve symptoms. Patients who do not respond to conservative therapies may undergo open or endoscopic carpal tunnel release for definitive treatment. Trigger finger, which involves abnormal resistance to smooth flexion and extension ("triggering") of the affected finger, affects up to 20% of adults with diabetes and approximately 2% of the general population. Steroid injection is the first-line therapy but is less efficacious in people with insulin-dependent diabetes. People with diabetes and those with recurrent symptoms may benefit from early surgical release. de Quervain tenosynovitis, consisting of swelling of the extensor tendons at the wrist, is more common in women than in men. People with frequent mobile phone use are at increased risk. The median age of onset is 40 to 59 years. Steroid injections relieve symptoms in approximately 72% of patients, particularly when combined with immobilization. People with recurrent symptoms may be considered for surgical release of the first dorsal extensor compartment. Thumb carpometacarpal joint arthritis affects approximately 33% of postmenopausal women, according to radiographic evidence of carpometacarpal arthritis. Approximately 20% of patients require treatment for pain and disability. Nonsurgical interventions (immobilization, steroid injection, and pain medication) relieve pain but do not alter disease progression. Surgery may be appropriate for patients unresponsive to conservative treatments.

Conclusions and Relevance

Carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, and thumb carpometacarpal joint arthritis can be associated with significant disability. First-line treatment for each condition consists of steroid injection, immobilization, or both. For patients who do not respond to noninvasive therapy or for progressive disease despite conservative therapy, surgical treatment is safe and effective.

Update on Efficacy of Conservative Treatments for Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is the most common upper extremity compression neuropathy. Non-operative interventions are usually the first-line treatments, and surgery is reserved for those that do not achieve a satisfactory symptom state by non-operative means. This narrative review summarizes the current evidence regarding the efficacy of orthoses, corticosteroid injections, platelet-rich plasma injections, Kinesio taping, neurodynamic techniques, gabapentin, therapeutic ultrasound, and extracorporeal shockwave therapy in people with CTS. While many trials suggest small short-term benefits, rigorous evidence of long-term patient-important benefits is limited. To improve the utility of healthcare resources, research in this area should focus on establishing efficacy of each treatment instead of comparing various treatments with uncertain benefits.