The clinical and cost effectiveness of steroid injection compared with night splints for carpal tunnel syndrome: the INSTINCTS randomised clinical trial study protocol

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.

The effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome: 24-month follow-up of a randomized trial

OBJECTIVES

This follow-up study of the INSTinCTS (INjection vs SplinTing in Carpal Tunnel Syndrome) trial compared the effects of corticosteroid injection (CSI) and night splinting (NS) for the initial management of mild-to-moderate CTS on symptoms, resource use and carpal tunnel surgery, over 24 months.

METHODS

Adults with mild-to-moderate CTS were randomized 1:1 to a local corticosteroid injection or a night splint worn for 6 weeks. Outcomes at 12 and 24 months included the Boston Carpal Tunnel Questionnaire (BCTQ), hand/wrist pain intensity numeric rating scale (NRS), the number of patients referred for and undergoing CTS surgery, and healthcare utilization. A cost-utility analysis was conducted.

RESULTS

One hundred and sixteen participants received a CSI and 118 a NS. The response rate at 24 months was 73% in the CSI arm and 71% in the NS arm. By 24 months, a greater proportion of the CSI group had been referred for (28% vs 20%) and undergone (22% vs 16%) CTS surgery compared with the NS group. There were no statistically significant between-group differences in BCTQ score or pain NRS at 12 or 24 months. CSI was more costly [mean difference £68.59 (95% CI: -120.84, 291.24)] with fewer quality-adjusted life-years than NS over 24 months [mean difference -0.022 (95% CI: -0.093, 0.045)].

CONCLUSION

Over 24 months, surgical intervention rates were low in both groups, but less frequent in the NS group. While there were no differences in the clinical effectiveness of CSI and NS, initial treatment with CSI may not be cost-effective in the long-term compared with NS.

Effectiveness of therapeutic ultrasound for the treatment of carpal tunnel syndrome (the USTINCTS trial): study protocol for a three-arm, prospective, multicentre, randomised controlled trial

INTRODUCTION

There has no consensus on optimal management of carpal tunnel syndrome (CTS), the most common compression neuropathy. Conservative therapy is generally accepted as first-line intervention. Therapeutic ultrasound has been widely reported to be treatment beneficial in nerve regeneration and conduction, and further accelerate compression recovery. The purpose of this study is to investigate the effectiveness of therapeutic ultrasound for CTS treatment.

METHODS AND ANALYSIS

This study protocol entails a three-arm, prospective, multicentre, randomised controlled trial. 162 eligible adult participants diagnosed with mild to moderate CTS by using criteria developed from a consensus survey by the UK Primary Care Rheumatology Society will be assigned to either (1) therapeutic ultrasound, (2) night splint or (3) therapeutic ultrasound +night splint (combined) group. Primary outcome will be difference in Symptom Severity Scale of Boston Carpal Tunnel Questionnaire (BCTQ-SSS) at 6-week between night splint and therapeutic ultrasound +night splint groups. Secondary outcomes include Functional Status Scale of BCTQ, sleep questionnaire for interrupted sleep, EuroQol-5D for general health, Hospital Anxiety and Depression Scale for mental status, Work Limitations Questionnaire-25 for functional limitations at work, Global Rating of Change for treatment success and recurrence rate, physical examination, electrophysiological and ultrasound parameters. Intention-to-treat analyses will be used.

ETHICS AND DISSEMINATION

Ethics committees of all clinical centres have approved this study. The leading centre is Shanghai Sixth People's Hospital, whose approval number is 2021-152. New versions with appropriate amendments will be submitted to the committee for further approval. Final results will be published in peer-reviewed journals and presented at local, national and international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2100050701.

High-resolution ultrasound demonstrates in vivo effects of wrist movement on the median nerve along the forearm

INTRODUCTION/AIMS

High-resolution ultrasound (HRUS) is the imaging method of choice to visualize peripheral nerve size, structure, and biomechanical performance. The purpose of this study was to show and quantify the effects of active and passive wrist alignment on median nerve (MN) cross-sectional area (CSA) along the forearm in a healthy population.

METHODS

Sixteen healthy volunteers underwent HRUS of their dominant forearm (n = 16, 10 males, 6 females, 18-55 y of age). Median nerve's CSA was assessed at four defined areas on the forearm in relation to active and passive wrist alignment.

RESULTS

Changes in wrist alignment were significantly associated with MN CSA (P < .001), regardless if the wrist was moved actively or passively. MN CSA was lowest during passive extension of the wrist joint and highest during passive flexion of the wrist joint (range: 4.5-23.2 mm² ).

DISCUSSION

The elasticity of nerve tissue, the loose connective tissue between the fascicles, and the paraneurium allow peripheral nerves to adapt to longitudinal strain. HRUS enables the demonstration of significant median nerve CSA changes along the forearm during active and passive wrist movement in healthy volunteers.

Health economic evaluation of different treatment strategies for peripheral entrapment mononeuropathies: a systematic review

Introduction: In this era of cost-conscious health systems, it is of utmost importance to identify and establish the most cost-effective treatment option. However, in the case of peripheral entrapment mononeuropathies there is alack of data regarding economically effective treatment strategies. Therefore, the objective was to conduct an economic evaluation including both costs and benefits of various treatment strategies applied to peripheral entrapment mononeuropathies to estimate the relative cost-effective treatment regimens.Areas covered: Over the 19 years, seven excellent-high quality economic evaluations of three types of peripheral entrapment mononeuropathies were identified in four countries. Our findings showed that surgery was the most cost-effective therapy followed by same cost efficacy of infiltrative therapy and conservative therapy for peripheral entrapment mononeuropathies. However, the fact that surgery was the most common comparator (n = 6) in our selected studies cannot be neglected.Expert opinion: Due to huge methodological variability, the finding of surgery as the cost-effective treatment strategy remains tentative and the decision about the most suitable clinical and cost-effective therapy should be individualized from case to case. Moreover, the economic evaluation of all possible treatment strategies for peripheral entrapment mononeuropathies over alonger period of analysis is required in future studies.

A systematic review of health economic evaluations in orthotics and prosthetics: Part 1 - prosthetics

BACKGROUND

The extent to which current prosthetic health economic evaluations inform healthcare policy and investment decisions is unclear. To further the knowledge in this area, existing evidence gaps and method design issues must be identified, thereby informing the design of future research.

OBJECTIVES

The aim of this systematic review was to identify evidence gaps, critical method design and reporting issues and determine the extent to which the literature informs a wide range of policy and investment decisions.

STUDY DESIGN

Systematic review.

METHODS

A range of databases were searched using intervention- and health economic evaluation-related terms. Issues with methodological design and reporting were evaluated using the Consolidated Health Economic Checklist - Extended and the Checklist for Health Economic Evaluation Reporting Standards.

RESULTS

The existing health economic evaluation literature was narrowly focused on informing within-participant component decisions. There were common method design (e.g. time horizon too short) and reporting issues (e.g. competing intervention descriptions) that limit the extent to which this literature can inform policy and investment decisions.

CONCLUSION

There are opportunities to conduct a wider variety of health economic evaluations to support within- and across-sector policy and investment decisions. Changes to aspects of the method design and reporting are encouraged for future research in order to improve the rigour of the health economic evaluation evidence.

CLINICAL RELEVANCE

This systematic review will inform the clinical focus and method design of future prosthetic health economic evaluations. It will also guide readers and policy-makers in their interpretation of the current literature and their understanding of the extent to which the current literature can be used to inform policy and investment decisions.

The clinical and cost-effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome (INSTINCTS trial): an open-label, parallel group, randomised controlled trial

BACKGROUND

To our knowledge, the comparative effectiveness of commonly used conservative treatments for carpal tunnel syndrome has not been evaluated previously in primary care. We aimed to compare the clinical and cost-effectiveness of night splints with a corticosteroid injection with regards to reducing symptoms and improving hand function in patients with mild or moderate carpal tunnel syndrome.

METHODS

We did this randomised, open-label, pragmatic trial in adults (≥18 years) with mild or moderate carpal tunnel syndrome recruited from 25 primary and community musculoskeletal clinics and services. Patients with a new episode of idiopathic mild or moderate carpal tunnel syndrome of at least 6 weeks' duration were eligible. We randomly assigned (1:1) patients (permutated blocks of two and four by site) with an online web or third party telephone service to receive either a single injection of 20 mg methylprednisolone acetate (from 40 mg/mL) or a night-resting splint to be worn for 6 weeks. Patients and clinicians could not be masked to the intervention. The primary outcome was the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ) at 6 weeks. We used intention-to-treat analysis, with multiple imputation for missing data, which was concealed to treatment group allocation. The trial is registered with the European Clinical Trials Database, number 2013-001435-48, and ClinicalTrial.gov, number NCT02038452.

FINDINGS

Between April 17, 2014, and Dec 31, 2016, 234 participants were randomly assigned (118 to the night splint group and 116 to the corticosteroid injection group), of whom 212 (91%) completed the BCTQ at 6 weeks. The BCTQ score was significantly better at 6 weeks in the corticosteroid injection group (mean 2·02 [SD 0·81]) than the night splint group (2·29 [0·75]; adjusted mean difference -0·32; 95% CI -0·48 to -0·16; p=0·0001). No adverse events were reported.

INTERPRETATION

A single corticosteroid injection shows superior clinical effectiveness at 6 weeks compared with night-resting splints, making it the treatment of choice for rapid symptom response in mild or moderate carpal tunnel syndrome presenting in primary care.

FUNDING

Arthritis Research UK.