Effects of shock wave therapy in patients with carpal tunnel syndrome: a systematic review and meta-analysis

Current Insights into Carpal Tunnel Syndrome: Clinical Strategies for Prevention and Treatment

BACKGROUND

Carpal tunnel syndrome (CTS) is a condition that is caused by medial nerve compression, resulting in symptoms such as numbness, tightness, or weakness in the hand.

OBJECTIVES

The aim of the study was to find out the genetic modulation, mechanism, available treatment, and recommendation for carpal tunnel syndrome at its specific stage.

METHODS

Almost 200 papers were searched for this review article, and 145 articles were selected. The literature was collected from different sources like Google scholar, PubMed, a directory of open-access journals, and science.gov by using keywords, such as treatment, risk factors, recommendation, and clinical features of carpal tunnel syndrome.

RESULTS

The most efficient non-surgical treatment is methylprednisolone acetate, which reduces inflammation by acting on the glucocorticoid receptor in conjunction with immunofilling. It has also been used successfully as a second-line drug for the treatment of patients with mild or moderate conditions in order to provide relief. New non-pharmacological options include laser therapy in acupuncture, transcutaneous electric nerve stimulation (TENS), and sham therapy. Modern treatments like TENS, laser therapy, splints, and injections of methylprednisolone acetate have been demonstrated to be helpful in sporadic situations. For patients with mild and moderate problems, more research should be conducted that includes the combination of these surgical and non-surgical treatments.

CONCLUSION

We propose a multifunctional panel construct and define standard data items for future research into carpal tunnel syndrome. A discussion on idiopathic carpal tunnel syndrome, risk factors, combination of therapies, using guidelines-based recommendations and treatment should be initiated.

Electrophysiological assessment of radial shock wave therapy for carpal tunnel syndrome

This study presents an electrophysiological assessment of radial extracorporeal shock wave therapy on patients with carpal tunnel syndrome (CTS). Sixteen CTS subjects received radial extracorporeal shock wave therapy once a week for five consecutive weeks. Outcome performance was assessed using the Boston Carpal Tunnel Questionnaire (BCTQ) and electrodiagnostic measurements including a nerve conduction study of the median nerve and a compound muscle action potential (CMAP) scan of the abductor pollicis brevis muscle. The BCTQ and the sensory conduction test measurements were all statistically improved after the treatment. However, the motor conduction test measurements were not significantly different before and after the treatment. The CMAP scan examination revealed MScanFit motor unit number estimation (MUNE) was significantly higher after the treatment, while no significant change was found in StairFit MUNE and step index. These results confirmed the effectiveness of shock wave therapy for treating CTS symptoms and the associated sensory property changes. The reasons for the inconsistencies from different CMAP scan processing methods are worthwhile targets for further investigation.

Extracorporeal Shock Wave Therapy for the Treatment of Musculoskeletal Pain: A Narrative Review

Extracorporeal shock waves are high-intensity mechanical waves (500-1000 bar) of a microsecond duration with a morphology characterized by a rapid positive phase followed by a negative phase.

BACKGROUND

Extracorporeal shock waves have been used for pain treatment for various sub-acute and chronic musculoskeletal (MSK) problems since 2000. The aim of this article is to update information on the role of extracorporeal shock wave therapy (ESWT) in the treatment of various pathologies that cause MSK pain.

METHODS

Given that in the last two years, articles of interest (including systematic reviews and meta-analyses) have been published on less known indications, such as low back pain, nerve entrapments, osteoarthritis and bone vascular diseases, a literature search was conducted in PubMed, the Cochrane Database, EMBASE, CINAHL and PEDro, with the aim of developing a narrative review of the current literature on this topic. The purposes of the review were to review possible new mechanisms of action, update the level of evidence for known indications and assess possible new indications that have emerged in recent years.

RESULTS

Although extracorporeal shock waves have mechanical effects, their main mechanism of action is biological, through a phenomenon called mechanotransduction. There is solid evidence that supports their use to improve pain in many MSK pathologies, such as different tendinopathies (epicondylar, trochanteric, patellar, Achilles or calcific shoulder), plantar fasciitis, axial pain (myofascial, lumbar or coccygodynia), osteoarthritis and bone lesions (delayed union, osteonecrosis of the femoral head, Kienbock's disease, bone marrow edema syndrome of the hip, pubis osteitis or carpal tunnel syndrome). Of the clinical indications mentioned in this review, five have a level of evidence of 1+, eight have a level of evidence of 1-, one indication has a level of evidence of 2- and two indications have a level of evidence of 3.

CONCLUSIONS

The current literature shows that ESWT is a safe treatment, with hardly any adverse effects reported. Furthermore, it can be used alone or in conjunction with other physical therapies such as eccentric strengthening exercises or static stretching, which can enhance its therapeutic effect.

The effectiveness of biophysical agents in the treatment of carpal tunnel syndrome- an umbrella review

BACKGROUND

Our objective was to summarize, synthesize, and integrate the evidence evaluating the effectiveness of biophysical agents compared to other conservative treatments, for the management of carpal tunnel syndrome (CTS).

METHODS

This was an overview of systematic reviews (SRs). We searched several online databases and obtained SRs relating to managing CTS using biophysical agents. Two independent researchers screened and appraised the quality of the SRs using the A MeaSurement Tool to Assess systematic Reviews-2 appraisal tool. We extracted information related to study characteristics as well as the effectiveness of biophysical agents for CTS, the effect sizes, and between-group significances. We categorized the information based on the type of biophysical agent. We also performed a citation mapping and calculated the corrected covered area index.

RESULTS

We found 17 SRs addressing 12 different biophysical agents. The quality of the SRs was mainly critically low (n = 16) or low (n = 1). The evidence was inconclusive for the effectiveness of Low-level Laser therapy and favorable for the short-term efficacy of non-thermal ultrasound in improving symptom severity, function, pain, global rating of improvement, satisfaction with treatment, and other electrophysiological measures compared to manual therapy or placebo. Evidence was inconclusive for Extracorporeal Shockwave therapy, and favorable for the short-term effectiveness of Shortwave and Microwave Diathermy on pain and hand function. The corrected covered area index was lower than 35% indicating a low overlap of the SRs.

CONCLUSIONS

The findings were based on low-quality primary studies, with an unclear or high risk of bias, small sample sizes, and short follow-ups. Therefore, no recommendations can be made for the long-term effectiveness of any biophysical agents. High-quality evidence is needed to support evidence-based recommendations on the use of biophysical agents in the management of CTS.

PROSPERO REGISTRATION NUMBER

CRD42022319002, registered on 17/04/2022.

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.

A new diagnostic morphological parameter for the Carpal tunnel syndrome: The palmaris longus tendon cross-sectional area

Carpal tunnel syndrome (CTS) is correlated with increased intracarpal canal pressure (ICP). The effect of palmaris longus tendon (PLT) loading on ICP is documented in previous researches. PLT loading induces the greatest absolute increase in ICP. Therefore, to analyze the connection between the PLT and CTS, we newly made the measurement of the PLT cross-sectional area (PLTCSA). We assumed that PLTCSA is a reliable diagnostic parameter in the CTS. PLTCSA measurement data were acquired from 21 patients with CTS, and from 21 normal subjects who underwent wrist magnetic resonance imaging (W-MRI). We measured the PLTCSA at the level of pisiform on W-MRI. The PLTCSA was measured on the outlining of PLT. The two different cutoff values in the analysis were determined using receiver operating characteristic (ROC) analysis. The mean PLTCSA was 2.34 ± 0.82 mm2 in the normal group and 3.97 ± 1.18 mm2 in the CTS group. ROC curve analysis concluded that the best cutoff point for the PLTCSA was 2.81 mm2, with 76.2% sensitivity, 71.4% specificity, and area under the curve of 0.88 (95% CI, 0.78-0.98). PLTCSA is a sensitive, new, objective morphological parameter for evaluating CTS.

Extracorporeal Shock Wave Therapy Provides Limited Therapeutic Effects on Carpal Tunnel Syndrome: A Systematic Review and Meta-Analysis

Night wrist splinting has been a conservative treatment for carpal tunnel syndrome. The addition of extracorporeal shock wave therapy provides an alternative treatment. However, strong evidence on the clinical effectiveness of extracorporeal shock wave therapy for carpal tunnel syndrome is still lacking. This study aimed to investigate the effectiveness and safety of extracorporeal shock wave therapy compared with treatments of night wrist splints alone for patients with carpal tunnel syndrome. In this systematic review and meta-analysis, no limitation criteria were used for study selection. All available articles that compare the effectiveness between extracorporeal shock wave therapy combined with night wrist splint and night wrist splint alone for treating carpal tunnel syndrome published up to 20 January 2022 were identified from the databases of PubMed, Embase, and Cochrane Central Register of Controlled Trials Central. The primary outcomes were a standard mean difference with a 95% confidence interval on the improvement of symptom severity and functional impairment between the two groups. In an attempt to analyze trends over time in studies that report repeated measurements, an all time-points meta-analysis (ATM) was undertaken. Seven randomized controlled trials with a total of 376 participants were included in this study. Significant improvements in functional impairment and symptom remission were only observed in the extracorporeal shock wave group at four weeks post-treatment. Extracorporeal shock wave therapy did not demonstrate superior efficacy compared to treatment with night wrist splint alone at 8-10 and 12-14 weeks post-treatment, or through the ATM approach. In conclusion, the therapeutic effect of extracorporeal shock wave therapy is transient and mostly nonsignificant compared with using night wrist splint alone. No serious side effects were reported in all included studies. Other conservative treatments to ameliorate carpal tunnel syndrome symptoms are warranted.

The effect of radial shockwave on the median nerve pathway in patients with mild-to-moderate carpal tunnel syndrome: a randomized clinical trial

Background

This study aimed to evaluate the short-term effect of radial shockwave on the median nerve pathway as a new model method in patients with mild-to-moderate carpal tunnel syndrome.

Methods

In this randomized clinical trial, 60 patients were randomly allocated into three equal groups. The first group received 1500 shocks on the carpal tunnel, the second group received 1500 shocks on the carpal tunnel and median nerve pathways, and the third group was the control group. In all three groups, patients received conventional physiotherapy for ten sessions. In addition, patients in experimental groups received four sessions of radial shockwave. Pain and paresthesia intensity, sensory and motor distal latency were evaluated as primary outcomes. Boston carpal tunnel Questionnaire scores were evaluated as secondary outcomes. Evaluations were performed at baseline, 1 and 4 weeks after the end of the treatment.

Results

Pain and paresthesia intensity and Boston questionnaire score significantly decreased in all three groups, but the greater improvement was noted in shockwave groups. Sensory and motor distal latency were only improved in shockwave groups. In terms of clinical and electrophysiological parameters, two groups of shockwaves showed similar results.

Conclusions

Radial shockwave combined with conventional physiotherapy is an effective noninvasive treatment for mild-to-moderate carpal tunnel syndrome that produces greater and longer-lasting results than conventional physiotherapy alone. There were no differences observed between utilizing radial shockwave on the carpal tunnel or median nerve pathways on the palmar surface of the hand, in terms of clinical and electrophysiological measurements.

Clinical Trial registration number The study was registered at https://fa.irct.ir/user/trial/49490/view (20200706048028N1) in date of 08/24/2021.