Current options for nonsurgical management of carpal tunnel syndrome

Occupational Carpal Tunnel Syndrome: a scoping review of causes, mechanisms, diagnosis, and intervention strategies

Carpal Tunnel Syndrome (CTS) has traditionally been viewed as a specialized medical condition. However, its escalating prevalence among professionals across a multitude of industries has sparked substantial interest in recent years. This review aims to delve into CTS as an occupational disease, focusing on its epidemiological patterns, risk factors, symptoms, and management options, particularly emphasizing its relevance in professional environments. The complex interaction of anatomical, biomechanical, and pathophysiological factors that contribute to the development of CTS in different work settings underlines the critical role of ergonomic measures, prompt clinical identification, and tailored treatment plans in reducing its effects. Nevertheless, the challenges presented by existing research, including diverse methodologies and definitions, highlight the need for more unified protocols to thoroughly understand and tackle this issue. There's a pressing demand for more in-depth research into the epidemiology of CTS, its injury mechanisms, and the potential role of targeted medicine. Moreover, recognizing CTS's wider ramifications beyond personal health is essential. The economic burden associated with CTS-related healthcare costs, productivity losses, and compensation claims can significantly impact both businesses and the broader society. Therefore, initiatives aimed at preventing CTS through workplace interventions, education, and early intervention programs not only benefit the affected individuals but also contribute to the overall well-being of the workforce and economic productivity. By fostering a collaborative approach among healthcare professionals, employers, policymakers, and other stakeholders, we can strive towards creating safer and healthier work environments while effectively managing the challenges posed by CTS in occupational settings.

Diagnostic Accuracy of Integrating Ultrasound and Shear Wave Elastography in Assessing Carpal Tunnel Syndrome Severity: a Prospective Observational Study

Purpose

Carpal tunnel syndrome (CTS) is a common condition characterized by compression of the median nerve (MN) within the carpal tunnel. Accurate diagnosis and assessment of CTS severity are crucial for appropriate management decisions. This study aimed to investigate the combined diagnostic utility of B-mode ultrasound (US) and shear wave elastography (SWE) for assessing the severity of CTS in comparison to electrodiagnostic tests (EDT).

Materials and Methods

This prospective observational study was conducted over 9-month periods at a tertiary care hospital. A total of 48 patients (36 females, 12 males; mean age 44 ± 10.9 years; age range 28-57 years) with clinically suspected CTS were enrolled. All patients underwent EDT, US, and SWE. Based on the EDT results, CTS cases were categorized into four groups: mild, moderate, severe, and negative. The cross-sectional area (CSA) and elasticity (E) of the MN were measured at the tunnel inlet (CSAu and Eu) and pronator quadratus region (CSAo and Eo). The differences (CSAu-CSAo and Eu-Eo) were calculated. The primary outcomes were the diagnostic performance of CSAu, CSAu-CSAo, Eu, and Eu-Eo in differentiating moderate/severe from mild/negative CTS compared to EDT findings. Secondary outcomes included a correlation of US/SWE parameters with EDT grades and between each other. ANOVA, correlation, regression, and receiver operating characteristic (ROC) curve analyses were performed.

Results

CSAu and CSAu-CSAo increased progressively with worsening CTS severity. E measurements were significantly higher in moderate-to-severe CTS compared to mild or negative cases. The combined metric of CSAu-CSAo at a 5 mm threshold exhibited enhanced performance, with a higher sensitivity (83.3%), specificity (100%), and area under the curve (AUC) (0.98), surpassing the results of CSAu when used independently. Similarly, the SWE measurements indicated that Eu-Eo at a 56.1kPa cutoff achieved an AUC of 0.95, with a sensitivity of 93.3% and specificity of 94.4%, outperforming the metrics for Eu when used alone, which had an AUC of 0.93, with identical sensitivity and specificity values (93.3% and 94.4%, respectively).

Conclusion

The integration of ultrasound, shear wave elastography, and electrodiagnostic tests provides a comprehensive approach to evaluate anatomical and neurological changes and guide management decisions for CTS.

Aesthetic and Functional Outcomes of Open Carpal Tunnel Release and Thread Carpal Tunnel Release: A Randomized Clinical Trial

Background and Objectives  Surgical techniques for carpal tunnel release (CTR) have gradually become less invasive. No substantial evidence supports replacing the open carpal tunnel release (OCTR) with novel minimally invasive approaches. Thread carpal tunnel release (TCTR) is a new minimally invasive CTR method associated with promising results. This study aimed to compare the aesthetic and functional outcomes of OCTR with TCTR. Materials and Methods  This study was a randomized clinical trial conducted in a hospital in Tehran, Iran, in 2022. Patients were randomized to OCTR and TCTR groups through simple randomization. Data such as demographics, nerve conduction study, electromyography, pain, and sensory evaluation by monofilament test were recorded in patients at baseline and after 3 months. Aesthetic evaluation was conducted by assessing the scar length and patients' satisfaction 3 months after the surgery. Results  Twenty patients (10 in each group) entered the final analysis. Nerve conduction study, electromyography, and sensory evaluation were similar between groups 3 months after the operation. The TCTR group had lower postsurgical pain ( p  < 0.001) and lower scar length ( p  < 0.001) compared to the OCTR group. Overall satisfaction was not statistically different between TCTR and OCTR. Conclusion  The TCTR method is safe in patients with CTS, and its efficacy is similar to OCTR. It can be a good alternative for OCTR, with a better aesthetic outcome.

Prevalence, Awareness, and Management of Carpal Tunnel Syndrome Among Diabetic Patients

BACKGROUND

Carpal tunnel syndrome (CTS) is a common condition that can significantly affect the quality of life for individuals, particularly those with diabetes. This study aims to examine the severity of CTS symptoms among diabetic patients and explore the associations between demographic factors, diabetic characteristics, knowledge, and management approaches.

METHODOLOGY

A cross-sectional study was conducted among diabetic patients, and data were collected using standardized questionnaires. The incidence and severity of CTS were assessed using the Boston Carpal Tunnel Questionnaire (BCTQ). Demographic information, diabetic characteristics, knowledge of CTS, and management approaches were also recorded. Descriptive statistics and inferential analysis were performed to analyze the data.

RESULTS

The study included 303 participants. The majority of the participants were aged 50 or older (44.9%) (N=136), followed by those aged 39-49 (24.4%) (N=74). In terms of gender, there were more female participants (61.4%) (N=186) than male participants (38.6%) (N=117). Older age groups exhibited higher mean BCTQ scores, suggesting increased severity. Females had significantly higher severity scores compared to males (mean BCTQ score of 17.52 vs 15.56). Regarding diabetic characteristics, complications in the eye and pain/numbness in the legs or feet were significantly associated with higher severity scores of CTS (P=0.0001). The study revealed a knowledge gap among diabetic patients about CTS, with inadequate knowledge about its causes, symptoms, consequences, and treatment options among 68.6% of the patients. The use of medical interventions such as splints, injections, and surgery was associated with higher severity scores.

CONCLUSION

This study highlights the incidence and severity of CTS symptoms among diabetic patients and its associations with demographic factors, diabetic characteristics, knowledge, and management approaches. Older age, female gender, widowed, diabetic complications in the eye, and pain/numbness in the legs or feet were found to be related to increased severity of CTS. Additionally, inadequate knowledge about CTS was observed among diabetic patients.

A Comparative Study of Effectiveness of Splinting and Splinting Plus Local Corticosteroid Injection in Patients With Carpal Tunnel Syndrome: A Randomized Controlled Trial

Introduction Corticosteroid injection and wrist-hand splint are two of the most commonly used conservative options for the management of carpal tunnel syndrome (CTS). This study compares the effectiveness of splinting and splinting plus local steroid injection in improving clinical and nerve conduction findings of patients with CTS. Methods A total of 44 patients with CTS were randomized into two groups. Group A used a full-time neutral wrist splint and group B was injected with 20 mg of triamcinolone acetonide and was given a full-time neutral wrist splint for 12 weeks. Clinical and nerve conduction findings of the patients were evaluated at baseline, 4 and 12 weeks after interventions. The chi-square test was used to test the association of different study variables. Z-test was used to test the significant difference between the two proportions. The means were compared by t-test. ANOVA was used to compare more than two mean values. Results The mean difference of the Boston Carpal Tunnel Questionnaire and median nerve latency at baseline and 12th week after treatment was significantly higher in group B than in group A (p<0.05). In intragroup comparison, there was significant improvement in the patient satisfaction, and clinical and nerve conduction values between the baseline level and 4 weeks after intervention and between the baseline and 12 weeks after intervention (P < 0.01). However, the inter-group comparisons were not significant. Conclusion Both of the management methods (splinting plus corticosteroid injection and splinting) have significant effects on the improvement of symptoms, and functional and nerve conduction status. It seems that splinting plus corticosteroid injection has a little edge over splinting alone during the follow-up periods.

Neurodynamic Techniques in the Treatment of Mild-to-Moderate Carpal Tunnel Syndrome: A Systematic Review and Meta-Analysis

Carpal tunnel syndrome (CTS) is a condition that affects the main nerves in the wrist area that causes numbness, tingling, and weakness in the hand and arm. CTS affects 5% of the general population and results in pain in the wrist due to repetitive use, most commonly affecting women and office workers. Conservative management of CTS includes neurodynamic modulation to promote median nerve gliding during upper limb movements to maintain normal function. However, evidence for the benefits of neurodynamic modulation found disparities, and hence, the effectiveness of neurodynamic modulation remains unclear. This study aimed to systematically review the current evidence from randomized controlled trials (RCTs) to establish the effectiveness of neurodynamic techniques as a non-surgical treatment option for CTS. Using the PRISMA guidelines, two authors searched four electronic databases, and studies were included if they conformed to pre-established eligibility criteria. Primary outcome measures included outcomes from the Boston carpal tunnel syndrome questionnaire, while secondary outcomes included nerve conduction velocity, pain, and grip strength. Quality assessment was completed using the Cochrane RoB2 form, and a meta-analysis was performed to assess heterogeneity. Twelve RCTs met our inclusion/exclusion criteria with assessments on 1003 participants in the treatment and control arms. High heterogeneity and some risks of bias were observed between studies, but the results of the meta-analysis showed a significant reduction in our primary outcome, the Boston carpal tunnel syndrome questionnaire-symptom severity scale (mean difference = -1.20, 95% CI [-1.72, -0.67], p < 0.00001) and the Boston carpal tunnel syndrome questionnaire-functional severity scale (mean difference = -1.06, 95% CI [-1.53, -0.60], p < 0.00001). Secondary outcomes such as sensory and motor conduction velocity increased significantly, while motor latency was significantly reduced, all positively favoring neurodynamic techniques. Pain was also significantly reduced, but grip strength was not significantly different. Our systematic review demonstrates significant benefits of neurodynamic modulation techniques to treat CTS and specifically that it reduces symptom severity, pain, and motor latency, while at the same time improving nerve conduction velocities. Hence, our study demonstrates a clear benefit of neurodynamic techniques to improve recovery CTS.

Endoscopic carpal surgery in carpal tunnel syndrome: A systematic review

Objective

Endoscopic carpal tunnel release has become increasingly popular and has shown the advantage of early recovery of hand function with minimal morbidity. In this systematic review, we aimed to summarize the currently available data and describe the reported advantages and disadvantages of endoscopic carpal tunnel surgery for treating carpal tunnel syndrome.

Methods

In this study, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, which is a set of reporting requirements for systematic reviews and meta-analyses. The search strategy with MeSH terms was "MeSH (carpal tunnel syndrome) AND (endoscopic)" Filters: in the last 5 years, English-on February 27th, 2022. A total of 131 articles fulfilled the first screening criteria. A detailed analysis of those articles identified 39 that matched the criteria, of which 14 were considered appropriate for this analysis after applying the complete inclusion and exclusion criteria.

Results

A total of 14 studies met the eligibility criteria. Analysis of those studies found that all types of portals in endoscopic carpal tunnel release reduced postoperative pain at a short-term follow-up. There was no evidence to suggest the superiority of the single- or two-portal techniques in terms of outcomes. In terms of pain relief, symptom resolution, patient satisfaction, duration to return to work, and adverse events, this early use of endoscopic carpal tunnel release produced satisfactory outcomes. Further studies comparing the number of portals are needed.

Conclusion

Endoscopic carpal tunnel surgery for treating carpal tunnel syndrome is effective and both single- and dual-portal techniques provide advantages in terms of early recovery and minimal morbidity.

Serum Transforming Growth Factor β1 and Its Genetic Variants Are Associated with Increased Macrophage Inflammatory Protein 1β and Susceptibility to Idiopathic Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is a common entrapment neuropathy in which one of the body's peripheral nerves becomes pinched or crushed. Transforming growth factor beta 1 (TGF-β1) plays an important role in the pathogenesis of CTS. An association between TGF-β1 polymorphisms and the susceptibility or progression of a number of diseases has been reported. In this study, three TGF-β1 single nucleotide polymorphisms (SNPs), serum TGF-β1, and macrophage inflammatory protein 1 beta (MIP-1β) were investigated as potential diagnostic markers for the progression of CTS in Egyptian patients. One hundred CTS patients and 100 healthy controls were recruited for the study. TGF-β1 SNPs +915G/C, -509C/T and -800G/A were determined by TaqMan genotyping assay. Serum TGF-β1 and MIP-1β levels were measured by ELISA. Serum TGF-β1 and MIP-1β levels increased significantly and were strongly correlated with the occurrence of CTS. The C allele of +915G/C, the T allele of -509C/T, and the G allele of -800G/A occurred more frequently in patients from CTS than in controls. The serum levels of TGF-β1 and MIP-1β in the group of carriers of the genotypes +915G/C GC and CC, the genotype -509C/T TT and the genotype -800G/A GA and AA were significantly higher in CTS patients. TGF-β1 and its +915G/C, -509C/T, and -800G/A SNPs and MIP-1β could be useful prognostic markers for the occurrence of CTS.

Dynamic ultrasound for evaluating the adequacy of median nerve decompression following minimally invasive carpal tunnel release: technical innovation and case study

Background

Minimally invasive carpal tunnel release has recently emerged as the primary surgical approach for recalcitrant carpal tunnel syndrome. A major concern related to surgical failure with this technique is the incomplete release of the flexor retinaculum.

Case presentation

We developed a technique using dynamic ultrasound for evaluating the adequacy of median nerve decompression following minimally invasive carpal tunnel release. This novel imaging method was applied to two patients who showed significant symptom relief after the intervention. This case study also provides details of the dynamic ultrasound protocol and highlights the advantages of this technique.

Conclusion

Dynamic ultrasound imaging can be used to confirm the completeness of carpal tunnel decompression. A large-scale prospective trial should be conducted to validate whether additional dynamic ultrasound examination can improve the outcome of minimally invasive carpal tunnel release.

The Effects of Physiotherapy in the Treatment of Cubital Tunnel Syndrome: A Systematic Review

Background: To date, various forms of physiotherapy are used in the treatment of cubital tunnel syndrome (CuTS). The effectiveness of physiotherapy for CuTS is inconclusive. The aim of this systematic review was to evaluate the effects of physiotherapy in the conservative treatment of CuTS. Methods: The six databases were searched from December 2020 to March 2022. The inclusion criteria were randomised controlled trials, case series, and case reports that evaluate the effects of physiotherapy in the treatment of adult participants with diagnosis CuTS. A total of 11 studies met the eligibility criteria, capturing a total of 187 participants. Results: In three types of papers, pain, muscle strength, and limitation of upper limb function were the most frequently assessed characteristics. Physiotherapy was most often based on manual therapy, neurodynamic techniques, and electrical modalities. One clinical trial rated the risk of bias “high” and the other two “some concerns”. In case-series designs, five studies rated the risk of bias as “serious” and three as “moderate”. Most of the studies showed a significant improvement in the clinical condition, also in the follow-up study. Only one clinical trial showed no therapeutic effect. Conclusion: There is no possibility of recommending the best method of physiotherapy in clinical practice for people with CuTS based on the results of this systematic review. More high-quality studies are required.

Ultrasound-guided 5% dextrose prolotherapy versus corticosteroid injection in carpal tunnel syndrome: a randomized, controlled clinical trial

Aim: The main assessment of this study is to analyze the efficiency of ultrasound-guided dextrose prolotherapy against corticosteroid injections for the treatment of carpal tunnel syndrome. Materials & methods: A total of 54 patients with carpal tunnel syndrome were included. Patients who were assigned into the prolotherapy group were injected with 5cc 5% dextrose water under ultrasound guidance. Patients in the corticosteroid group received ultrasound-guided 1 ml triamcinolone 40 mg/ml injection. Results: The inter-group analysis revealed that dextrose prolotherapy has a similar efficacy as corticosteroid for improving pain intensity, functional limitation in daily life, electrophysiologic parameters and ultrasonographic outcomes. No remarkable difference was found between the two treatments until 3 months of follow-up. Conclusion: Dextrose 5% has similar efficacy as triamcinolone for improving pain intensity, functional limitation in daily life, electrophysiologic parameters and ultrasonographic outcomes.

Assessment of L-carnitine effectiveness on carpal tunnel syndrome

Background: Carpal tunnel syndrome (CTS) is the most prevalent entrapment neuropathy. Due to the results of recent studies about the protective effects of L-carnitine on nerves, this study was conducted to evaluate the effects L-carnitine on CTS improvement in terms of patient's function, electrodiagnostic study (EDX), and median nerve sonography. Methods: In this double-blind, randomized, controlled trial, patients with CTS were selected based on the inclusion and exclusion criteria, and then, divided into two groups of placebo and L-carnitine at a dose of 500 mg twice daily for 6 weeks. They were assessed at baseline, and 4 and 6 weeks later using Boston Carpal Tunnel Questionnaire (BCTQ)‎, median nerve conduction study (EDX), and sonography. Results: There was no statistically significant difference between the intervention and control groups in terms of BCTQ‎ scores, electrodiagnostic findings, and sonographic indexes. Although based on the results of the repeated measures test of the intervention and control groups separately, there was a statistically significant difference in some electrodiagnostic criteria and BCTQ‎ scores. These indexes improved after the intervention. Conclusion: The effectiveness of L-carnitine on mild to moderate CTS improvement cannot be approve based on the findings of this study and more studies and systematic reviews are required in this regard.

The Effect of Shock Wave and Phonophoresis in the Improvement of the Clinical Symptoms and Function of Patients with Mild to Moderate Carpal Tunnel Syndrome: A Clinical Trial

Background: Carpal tunnel syndrome is a common condition that causes pain, sensory and motor symptoms in the hands, especially in the thumb, index, and middle fingers due to the compression of the median nerve in the carpal tunnel. The purpose of this research was to investigate the effect of the shock wave and phonophoresis in the improvement of clinical symptoms and function of patients with mild to moderate carpal tunnel syndrome. Methods: The present research has employed a double-blind randomized clinical trial on 60 patients in Isfahan, Iran. Patients were randomly divided into 3 treatment groups of shock, phonophoresis, and control, and all patients received conservative treatments. Wrist thermoplastic splint, vitamin B1, and celecoxib were prescribed for all patients. The shock group received their intervention in four sessions of shock once a week for 4 weeks. Patients in the phonophoresis group received phonophoresis (pulse 1:4) 15 minutes every other day for 2 weeks. Pain scores were assessed based on the visual analog pain scale, and the Boston questionnaire severity scale was completed for each patient before, 1 and 2 months after the intervention. The used analytic tests included Fisher's exact tests, 1-way analysis of variance, and repeated measures analysis. Results: Shock wave and phonophoresis showed a significant decrease in pain, symptom severity index (p<0.001), and functional status (p<0.001). This reduction was more persistent in the phonophoresis group. Conclusion: The use of noninvasive shock wave and phonophoresis methods were good alternatives in the treatment of carpal tunnel syndrome.

Does Societal Cost Information Affect Patient Decision-Making in Carpal Tunnel Syndrome? A Randomized Controlled Trial

Background: Despite studies demonstrating the effects of out-of-pocket costs on decision-making, the effect of societal cost information on patient decision-making is unknown. Given the considerable societal impact of cost of care for carpal tunnel syndrome (CTS), providing societal cost data to patients with CTS could affect decision-making and provide a strategy for reducing national health care costs. Therefore, we assessed the following hypotheses: (1) there is no difference in treatment choice (surgery vs no surgery) in a hypothetical case of mild CTS between patients randomized to receive societal cost information compared with those who did not receive this information; (2) there are no factors (eg, sex, experience with a previous diagnosis of CTS, or receiving societal cost information) independently associated with the choice for surgery; and (3) there is no difference in attitudes toward health care costs between patients choosing surgery and those who did not. Methods: In this randomized controlled trial using a hypothetical scenario, we prospectively enrolled 184 new and return patients with a nontraumatic upper extremity diagnosis. We recorded patient demographics, treatment choice in the hypothetical case of mild CTS, and their attitudes toward health care costs. Results: Treatment choice was not affected by receiving societal cost information. None of the demographic or illness factors assessed were independently associated with the choice for surgery. Patients declining surgery felt more strongly that doctors should consider their out-of-pocket costs when making recommendations. Conclusions: Providing societal cost information does not seem to affect decision-making and may not reduce the overall health care costs. For patients with CTS, health policy could nudge toward better resource utilization and finding the best care pathways for nonoperative and invasive treatments.

Nonsurgical Treatment for Symptomatic Carpal Tunnel Syndrome: A Randomized Clinical Trial Comparing Local Corticosteroid Injection Versus Night Orthosis

PURPOSE

For carpal tunnel syndrome (CTS), local corticosteroid injection (corticosteroid), and/or wrist immobilization with night orthosis (orthosis) are commonly prescribed and are supported by strong evidence. The aim of this study was to compare orthosis versus corticosteroid for patients with CTS.

METHODS

A CTS diagnosis was made clinically and supported by electrodiagnostic study. Patients were randomly allocated to either orthosis or corticosteroid. Clinical assessments were performed before the intervention, within the first week of the intervention, and 1, 3, and 6 months after the intervention. Primary outcomes were improvement in nocturnal paresthesia and Boston-Levine questionnaire (BLQ) score. Secondary outcomes were pain assessed by visual analog scale and complications.

RESULTS

Of 100 patients enrolled in the study, 95 completed the planned follow-up (45 in the orthosis arm and 50 in the corticosteroid arm). Corticosteroid injections were superior to orthosis in remission of nocturnal paresthesia (remission rates at 1 month, 84.6% versus 43.83%; 3 months, 71.1% versus 40.4%; and 6 months, 80.3% versus 28.8%). The BLQ scores (functional and symptom subscales) were also more favorable for corticosteroid at 1, 3, and 6 months (minimal clinically important differences for Function > 0.5 and Symptom > 0.16). Pain scores were lower and favored the corticosteroid group. There were no complications in either group.

CONCLUSIONS

Both options are effective in the short term. Corticosteroid is superior to orthosis for improving CTS-related nocturnal paresthesia, BLQ scores, and pain.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Long-term Results of Two Different Surgical Techniques Used in Carpal Tunnel Syndrome

Objective Carpal tunnel syndrome (CTS), the compression of the median nerve under the carpal ligament, is the most common peripheral nerve entrapment of the upper extremity. While conservative treatment is used for patients with mild and moderate symptoms, surgical treatment is preferred for severe symptoms. The aim of the study is to evaluate the difference between transverse and longitudinal incision by comparing postoperative pain and recurrence rates.

Methods The patients were divided into two groups according to the surgical incision type. Surgical intervention was applied to patients in group T (transverse incision) and group L (longitudinal incision) by the same two surgeons in each group. All patients were followed-up with electromyography (EMG) and performance scale before and after surgical treatment. If the postoperative EMG result was similar to the preoperative EMG result, it was accepted as recurrent CTS.

Results A total of 418 patients were included to the study. Six patients in the group T with transverse incision, and 18 patients in the group L with longitudinal incision, were reoperated for an average of 6 ± 2 months after the primary surgery.

Conclusion Complications are less, and recurrent nerve compression is less in longitudinal approach, since surgical intervention is performed by seeing the median nerve directly.

The Influence of Cost Information on Treatment Choice: A Mixed-Methods Study

PURPOSE

To test the null hypothesis that exposure to societal cost information does not affect choice of treatment for carpal tunnel syndrome (CTS).

METHODS

We enrolled 304 participants using the Amazon Mechanical Turk platform to complete a survey in which participants were given the choice between carpal tunnel release (CTR) or a less-expensive option (orthosis wear) in a hypothetical mild CTS scenario. Patients were randomized to receive information about the societal cost of CTR (cost cohort) or no cost information (control). The primary outcome was the probability of choosing CTR measured on a 6-point ordinal scale. We employed qualitative content analysis to evaluate participants' rationale for their choice. We also explored agreement with various attitudes toward health care costs on an ordinal scale.

RESULTS

Participants in the cost cohort exhibited a greater probability of choosing surgery than those in the control cohort. The relative risk of choosing surgery after exposure to societal cost information was 1.43 (95% confidence interval, 1.11-1.85). Among participants who had not previously been diagnosed with CTS (n = 232), the relative risk of choosing surgery after exposure to societal cost information was 1.55 (95% confidence interval, 1.17-2.06). Lack of personal monetary responsibility frequently emerged as a theme in those in the cost cohort who chose surgery. The majority (94%) of participants expressed at least some agreement that health care cost is a major problem whereas only 58% indicated that they consider the country's health care costs when making treatment decisions.

CONCLUSIONS

Participants who received societal cost information were more likely to choose the more expensive treatment option (CTR) for mild CTS.

CLINICAL RELEVANCE

Exposure to societal cost information may influence patient decision making in elective hand surgery. A complete understanding of this influence is required prior to implementing processes toward greater cost transparency for diagnostic/treatment options. Sharing out-of-pocket costs with patients may be a beneficial approach because discussing societal cost information alone will likely not improve value of care.

Platelet-rich plasma injection versus surgical and medical treatment of mild-moderate carpal tunnel syndrome

Abstract

Carpal tunnel syndrome (CTS) accounts for approximately 90% of peripheral entrapment neuropathy cases. Treatments of CTS as splinting, corticosteroid injection, and surgery are not 100% effective, and alternative treatments are worth exploring. Surgery indicated in patients with persistent numbness, pain, and motor dysfunction. Empirical evidence indicates that many patients with CTS respond to anti-inflammatory medications. Recently, major attention has been drawn to platelet-rich plasma (PRP) for its possible effects on axon regeneration and neurological recovery.

Objectives

To evaluate the therapeutic efficacy of single ultrasound guided PRP injection of CTS versus surgical procedures and medical treatment in patients with mild-moderate CTS regarding pain relief and function improvement.

Methods

Thirty patients were injected in the carpal tunnel with single ultrasound-guided PRP (1–2 ml) injections; 30 patients went to surgical procedure, and 30 patients received conventional medical treatment and hand support. They were followed by using VAS (visual analogue scale), Boston questionnaire for CTS, and nerve conduction study for clinical improvement.

Results

Both groups of patients who had received PRP injection and who underwent to surgery showed improvements in their scores of evaluation parameters at 6 months post intervention, while the third group that received medical treatment shows insignificant improvement at 6 months post treatment.

Conclusion

PRP can be considered as a safe, less invasive, and long-lasting alternative to surgery and effective with one shot session compared to medical treatment in management of mild-moderate CTS.

Trial registration

Clinical trial.govID: NCT04235426.

Unique protocol ID:1472.

Verification date: January 2020.

Ultrasound-Guided Corticosteroid Injection in Carpal Tunnel Syndrome: Comparison Between Radial and Ulnar Approaches

Purpose

To compare two common approaches for ultrasonography (US)-guided injection.

Patients and Methods

Sixty patients with mild-to-moderate CTS were included in this double-blind randomized controlled trial (RCT). They received a single shot of corticosteroid injection through either the US-guided in-plane approach: radial or ulnar side. Participants were evaluated using Boston Carpal Tunnel Questionnaire (BCTQ) and visual analogue scale (VAS) for pain, as well as electrodiagnosis (EDX) and US parameters before the intervention, and within 12 weeks of follow-up.

Results

In both groups, all outcomes, except for the electrodiagnostic measures, significantly improved within the follow-up. Pain-VAS and both subscales of BCTQ questionnaire, as our main subjective outcomes, revealed dramatic improvement, with the largest amount of changes in VAS (70%; comparing to baseline value), and about 37% for both of BQSS and BQFS scales, all indicating superiority of radial to ulnar in-plane approach. During the first follow-up, we did not detect any remarkable preference between the groups in either subjective or electrodiagnostic variables. However, there was a significant difference at next follow-up time-points in terms of VAS for pain and BQFS favoring radial approach (Table 3). Furthermore, US-measured parameters including nerve-circumference and CSA improved only in the radial in-plane group.

Conclusion

The current data proved that radial in-plane approach for CTS injection could be at least as effective as the more common ulnar in-plane method. Even the pain-relief effect was longer for the radial in-plane approach. Also, patients’ functional status and objective variables all revealed better outcomes via the new approach.

Endoscopic Carpal Tunnel Release

Carpal tunnel syndrome represents compression of the median nerve in the carpal tunnel, which is defined by the carpal bones on the lateral, medial, and dorsal aspects and the transverse carpal ligament on the anterior aspect.¹ Symptoms of carpal tunnel syndrome include paresthesia, anesthesia, paresis, and pain located in the median nerve distribution. In severe cases, there may be atrophy of median nerve-innervated thenar muscles. In the United States, carpal tunnel syndrome affects approximately 3.72% of the population.² Conservative measures, such as bracing, steroid injections, and physical and occupational therapy, are commonly employed.¹ However, many patients still require more definitive surgical management, which may be in the form of open or endoscopic procedures. Regardless of surgical approach, the clinical success rates of carpal tunnel release have been reported to be 75%-90%.³ Recurrence rates are 8.4%-15% over 4-5 years,^4,5 with the lower end of this range representing the Agee single-portal technique. Endoscopic carpal tunnel release leads to reduced postoperative pain and an increase in transient neurologic deficits; however, no improvements have been reported in overall complication rate, subjective satisfaction, return to work, postoperative grip and pinch strength, and operative time.⁶ In this technical video, we present a case of single-incision endoscopic carpal tunnel release in a patient with severe symptoms after conservative measures failed. The patient experienced a noncomplicated postoperative course and demonstrated an excellent recovery at follow-up visits. Surgical decompression is an important treatment for refractory carpal tunnel syndrome, and videos such as this provide guidance for safe and effective treatment (Video 1).

Physical Therapy and Rehabilitation Approaches in Patients with Carpal Tunnel Syndrome

Physical therapy involves a set of factors and methods that affect the biological processes in the body. It is widely used, relatively inexpensive, non-invasive, and easy to apply. Physiotherapy is also used in the treatment of patients with carpal tunnel syndrome (CTS). This syndrome represents the most common compressive mononeuropathy of the upper limb and leads to significant disability. Hence, its successful treatment leads to significant benefits for both the patient and society. There is no established algorithm for the use of physical therapy in these patients. In this publication, we present the physiotherapeutic methods used for the treatment of CTS both before and after surgical treatment.

Comparison of the effectiveness of orthotic intervention, kinesiotaping, and paraffin treatments in patients with carpal tunnel syndrome: A single-blind and randomized controlled study

PURPOSE

The aim of the study was to compare different conservative treatments in patients with carpal tunnel syndrome (CTS).

STUDY DESIGN

A single-blind randomized controlled study.

METHODS

Patients (n = 169) diagnosed with mild or moderate CTS were screened; 110 met study requirements. The patients were randomized into 3 groups. The control (CON) comparison provided to all patients was a fabricated night orthotic which held the wrist in a neutral position. The second group received adjunctive kinesiotaping (KIN) and the third group received paraffin (PARA). All patients were evaluated clinically, electrophysiologically, and ultrasonographically before treatment and at 3 weeks, 3 months, and 6 months.

RESULTS

There were 36 patients in CON, 37 in KIN, and 37 in PARA. Pain reduction in KIN was better than the other groups at 3 weeks (mean difference [MD] in CON 2.4 ± 2.5, KIN 3.7 ± 2.0, PARA 2.7 ± 2.3; P < .01) and 6 months (MD in CON 3.4 ± 3.0, KIN 4.9 ± 3.1, PARA 3.7 ± 2.9; P < .05). KIN pain reduction was better than CON at 3 months (MD in CON 3.8 ± 2.8, KIN 5.0 ± 2.5; P < .05). Reduction of the cross-sectional area of median nerve at the level of radioulnar joint was greater for KIN than CON at 3 weeks (MD in CON 0.0 ± 0.5, KIN 0.3 ± 0.7; P < .01) than PARA at 3 months (MD in KIN 0.3 ± 0.8, PARA 0.0 ± 0.8; P < .05) and both groups at 6 months (MD in CON 0.1 ± 0.8, KIN 0.5 ± 0.9, PARA 0.0 ± 1.0 P < .05).

CONCLUSION

Adding KIN to night use of an orthotic was more effective in achieving symptomatic and structural improvements than either the orthotic alone or adjunctive use of paraffin in patients with mild and moderate CTS.

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

BACKGROUND

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

AIM

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

DESIGN

Double-blind randomized controlled trial.

SETTING

Outpatient physiotherapy clinic.

POPULATION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL REHABILITATION IMPACT

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

A survey of client experiences with orthotics using the QUEST 2.0

INTRODUCTION

Hand orthoses are designed to relieve pain, immobilize a body part and protect the injury site, prevent or correct deformity, and promote healing in the body. Practitioners who prescribe and create orthoses are reliant on patient adherence to achieve desired outcomes in treatment. Understanding client preferences may promote better orthotic intervention outcomes.

PURPOSE OF THE STUDY

The purpose of this cross-sectional study was to determine the level of client satisfaction with device characteristics and service provision of custom-fabricated hand orthotics using the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) version 2.0 questionnaire.

METHODS

After approval from an institutional review board, participants for this study were obtained through a convenience sample from a hand rehabilitation clinic. Seventy-two participants were administered the QUEST 2.0 to evaluate their satisfaction regarding various aspects of their orthotic devices. The 12 satisfaction categories in the QUEST are dimensions, weight, adjustments, safety, durability, easy to use, comfort, effectiveness, service delivery, repairs/services, professional service, and follow-up service. Each question was scored on a 5-point Likert scale and then recorded in the following 3 sections: device, service, and total score. The mean and standard deviation were calculated for each of the 12 items to determine the primary determinants of orthotic satisfaction.

RESULTS

The top 3 categories for a participant's orthotic device characteristics were comfort (81%), effectiveness (75%), and ease of use (74%). The participants' mean score for the device section was 4.53. The mean service score was 4.71. The total mean score was 4.61.

CONCLUSION

Therapists who are fabricating prescribed orthotic devices for individuals should consider comfort, effectiveness, and ease of use as they fabricate and adjust the device for their client. Identifying the client's desired aspects of the device can help the therapist create a better therapeutic relationship with the client and may improve their overall experience receiving orthotic intervention.

A Tablet-Based App for Carpal Tunnel Syndrome Screening: Diagnostic Case-Control Study

BACKGROUND

Carpal tunnel syndrome (CTS), the most common neuropathy, is caused by a compression of the median nerve in the carpal tunnel and is related to aging. The initial symptom is numbness and pain of the median nerve distributed in the hand area, while thenar muscle atrophy occurs in advanced stages. This atrophy causes failure of thumb motion and results in clumsiness; even after surgery, thenar atrophy does not recover for an extended period. Medical examination and electrophysiological testing are useful to diagnose CTS; however, visits to the doctor tend to be delayed because patients neglect the symptom of numbness in the hand. To avoid thenar atrophy-related clumsiness, early detection of CTS is important.

OBJECTIVE

To establish a CTS screening system without medical examination, we have developed a tablet-based CTS detection system, focusing on movement of the thumb in CTS patients; we examined the accuracy of this screening system.

METHODS

A total of 22 female CTS patients, involving 29 hands, and 11 female non-CTS participants were recruited. The diagnosis of CTS was made by hand surgeons based on electrophysiological testing. We developed an iPad-based app that recorded the speed and timing of thumb movements while playing a short game. A support vector machine (SVM) learning algorithm was then used by comparing the thumb movements in each direction among CTS and non-CTS groups with leave-one-out cross-validation; with this, we conducted screening for CTS in real time.

RESULTS

The maximum speed of thumb movements between CTS and non-CTS groups in each direction did not show any statistically significant difference. The CTS group showed significantly slower average thumb movement speed in the 3 and 6 o'clock directions (P=.03 and P=.005, respectively). The CTS group also took a significantly longer time to reach the points in the 2, 3, 4, 5, 6, 8, 9, and 11 o'clock directions (P<.05). Cross-validation revealed that 27 of 29 CTS hands (93%) were classified as having CTS, while 2 of 29 CTS hands (7%) did not have CTS. CTS and non-CTS were classified with 93% sensitivity and 73% specificity.

CONCLUSIONS

Our newly developed app could classify disturbance of thumb opposition movement and could be useful as a screening test for CTS patients. Outside of the clinic, this app might be able to detect middle-to-severe-stage CTS and prompt these patients to visit a hand surgery specialist; this may also lead to medical cost-savings.

The effects of dry needling and neurodynamic exercise on idiopathic peripheral neuropathy: A case report

A single patient (male, 67) with a medical diagnosis of idiopathic peripheral neuropathy (G60.9) was referred to physical therapy. The patient presented with signs and symptoms consistent with peripheral neuropathy, including bilateral single leg balance deficits, sensation impairments, and antalgic gait. Treatment consisted of dry needling (DN) with electrical stimulation and a home exercise program involving a neurodynamic exercise to be performed daily. Dry needling included the use of thin filiform needles to stimulate the underlying structures directed at eliciting a change within the tissues. The needles were left in situ and connected to an electrical stimulation unit. The neurodynamic exercise used in this case study was designed to target the distal branches of the sciatic nerve. The patient was directed to complete 3 sets of 10 repetitions in the slumped position and moving between ankle plantar flexion and dorsiflexion. The patient was treated for a total of 4 visits over a 5-week period. The Foot and Ankle Ability Measure (FAAM), Numeric Pain Rating Scale (NPRS), Romberg Test, and sensation testing were collected at baseline and then again after the 4th treatment. A Global Rating of Change (GROC) score was obtained at the end of treatment. After the 4th visit, functional self-report scores were not improved (93.75%-86.9% at completion), while NPRS decreased to 2 from a baseline rating of 4. The eyes closed portion of the Rhomberg balance test improved from 5 s on the right limb to 15 s and from 8 s to 20 s on the left limb. Sharp/dull sensation testing of the L4 dermatome also improved from 2 out of 5 correctly selected on the left lower limb to 5 out of 5. At the S1 level, sensation improved on the left lower limb from 2 out of 5 to 4 out of 5 and from 2 out of 5 on the right lower limb to 5 out of 5. The patient's GROC score was rated as quite a bit better (+5). The outcomes of this case study suggest that clinicians may consider the addition of DN with electrical stimulation and neurodynamic exercises to the treatment of this patient population given the sizeable and rapid improvements in pain, balance, and sensation testing following only 4 treatments.

Analysis of Expected Costs of Carpal Tunnel Syndrome Treatment Strategies

BACKGROUND

Over 500 000 carpal tunnel releases costing over $2 billion are performed each year in the United States. The study's purpose is to perform a cost-minimizing analysis to identify the least costly strategy for carpal tunnel syndrome treatment utilizing existing success rates based on previously reported literature.

METHODS

We evaluate the expected cost of various treatment strategies based on the likelihood of further treatments: (1) a single steroid injection followed by surgical release; (2) up to 2 steroid injections before surgical release; (3) 3 steroid injections before surgery, and (4) immediate surgical release. To reflect costs, we use our institution's billing charges to private payers and reimbursements from Medicare. A range of expected steroid injection success rates are employed based on previously published literature.

RESULTS

Immediate surgical release is the costliest treatment with an expected cost of $2149 to $9927 per patient. For immediate surgical release to cost less than a single injection attempt, the probability of surgery after injection would need to exceed 80% in the Medicare reimbursement model and 87% in the institutional billing model. A single steroid injection with subsequent surgery, if needed, amounts to a direct cost savings of $359 million annually compared with immediate surgical release. Three injections before surgery, with "high" expected success rates, represent the cost-minimizing scenario.

CONCLUSIONS

Although many factors must be considered when deciding upon treatment for carpal tunnel syndrome, direct payer cost is an important component, and the initial management with steroid injections minimizes these direct payer costs.

Role of Biomechanical Factors in Resolution of Carpal Tunnel Syndrome Among a Population of Workers

OBJECTIVES

Identify if Carpal tunnel syndrome (CTS) symptoms vary by measured biomechanical exposures.

METHODS

A nested prospective cohort within a large, multicenter, 8-year cohort study. The CTS case definition was tingling/numbness in 2+ median nerve-served digits plus a nerve conduction study consistent with CTS. Workers were assigned to: (1) low (strain index [SI] less than or equal to 6.1), and (2) high (SI more than 6.1) job groups.

RESULTS

Among 1201 workers, 106 had CTS. Those in the high SI group became and remained symptom-free for at least 3 months, faster than the low SI group, adjusted hazard ratio (HR) = 2.07 (95% confidence interval [CI] = 1.21 to 3.56, P = 0.008). Only surgical release trended towards resolving CTS. Light duty had no impact, and job change was associated with delayed symptoms resolution.

CONCLUSIONS

High biomechanical exposures paradoxically predicted faster improvement in CTS and light duty did not result in symptom resolution.

Sonographic Measurement of Cross-sectional Area of the Median Nerve in Academic Dentists Without Symptoms or Signs of Carpal Tunnel Syndrome

The objective was to evaluate the distribution of the cross-sectional area (CSA) and flattening ratio (FR) of the median nerve (MN) in asymptomatic academic dentists using ultrasonography (US). Fifty academic dentists underwent US of the MN in transverse section at the pisiform bone level and the CSA (mm2) and FR were measured bilaterally. A CSA of <10 mm2 was considered normal. Paired t-test showed no statistical significance between either hand for CSA and FR ( P> .05). Two independent t-tests showed significant statistical differences ( P= .023) between males and females in the right dominant hand for CSA. Linear correlation analysis showed no significant correlation between CSA and FR for number of years of experience or number of working hours per day in either hand ( P>.05). The CSA was abnormal in the right dominant hand in 20 (40%) of the subjects. These male academic dentists were at increased risk of having an enlarged MN without symptoms.

Effects of diacutaneous fibrolysis in patients with mild to moderate symptomatic carpal tunnel syndrome: a randomized controlled trial

OBJECTIVE:

To compare the effects of diacutaneous fibrolysis with sham in patients with mild to moderate carpal tunnel syndrome.

DESIGN:

Double-blind (patient and evaluator) randomized controlled trial.

SETTING:

Miguel Servet University Hospital, Zaragoza, Spain.

SUBJECTS:

A total of 52 patients (72 wrists) with carpal tunnel syndrome, 41 women and 11 men, mean age was 46.9 (8.8) years. They were divided into two groups: diacutaneous fibrolysis group and sham group.

INTERVENTIONS:

Real diacutaneous fibrolysis in diacutaneous fibrolysis group and sham diacutaneous fibrolysis in sham group. Both groups received five sessions in the forearm, wrist and hand.

MAIN MEASURES:

Neurophysiological parameters assessed at baseline and at the end of the treatment. Intensity of nocturnal symptoms (visual analogue scale (VAS)) and upper limb functional capacity (Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire) at baseline, at the end of the treatment and one month after treatment.

RESULTS:

Diacutaneous fibrolysis group (n = 30 wrists) improved in nerve conduction distal motor latency (mean difference: -0.26, 95% confidence interval (CI): -0.49/-0.26), sensory conduction velocity (mean difference: 6.52, 95% CI: 3.52/9.51), intensity of nocturnal symptoms (mean difference: -2.24, 95% CI: -4.08/-2.04) and upper limb functional capacity (mean difference: -19, 95% CI: -26.1/-11.9) compared to the sham group (n = 30 wrists) ( P < 0.02, P < 0.01, P < 0.01 and P < 0.01, respectively). At one-month follow-up, improvements in the nocturnal symptoms and upper limb functional capacity were maintained compared to the sham group ( P < 0.01).

CONCLUSION:

Diacutaneous fibrolysis provides short-term and one-month follow-up, improvements in sensory conduction velocity, motor distal latency, symptoms and functional capacity in patients with mild to moderate carpal tunnel syndrome.

Comparison of single-dose radial extracorporeal shock wave and local corticosteroid injection for treatment of carpal tunnel syndrome including mid-term efficacy: a prospective randomized controlled trial

BACKGROUND

Recent studies have reported that radial extracorporeal shock wave therapy (rESWT) reduces pain and improves function in patients with mild to moderately severe carpal tunnel syndrome (CTS) compared to a placebo. However, most of those studies used multi-session rESWT combined with wrist support and evaluation of efficacy was limited to a maximum of 14 weeks.

METHODS

The prospective randomized controlled trial compared efficacy in relieving pain and improving clinical function between single-dose rESWT and local corticosteroid injection (LCsI) over the mid-term (24 weeks). Twenty-five patients with mild to moderately severe CTS were randomized to receive either single-dose rESWT (n = 13) or LCsI (n = 12). Primary outcomes were evaluated using the Boston self-assessment questionnaire (BQ), while secondary outcomes used the Visual analogue scale (VAS) and electrodiagnostic parameters. Evaluations at baseline and at 1, 4, 12 and 24 weeks after treatment were performed.

RESULTS

There was significantly greater improvement in symptom severity scores, functional scores and Boston questionnaire scores at weeks 12 to 24 in the rESWT group compared to the LCsI group. When compared to the baseline, there was significant reduction of VAS and functional score in the rESWT group at weeks 12 and 24. The LCsI group had no statistically significant differences in VAS reduction and functional score of the same period.

CONCLUSIONS

Treatment of CTS using single-dose rESWT has a carry-over effect lasting up to 24 weeks suggesting that single-dose rESWT is appropriate for treatment of mild to moderate CTS and provides longer-lasting benefits than LCsI.

TRIAL REGISTRATION

( TCTR20150709001 ). Registered 9 July 2015.

Ultrasound-Guided Versus Landmark-Guided Local Corticosteroid Injection for Carpal Tunnel Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

To review the literature and assess the comparative effectiveness of ultrasound-guided versus landmark-guided local corticosteroid injections in patients with carpal tunnel syndrome (CTS).

DATA SOURCES

Cochrane Central Register of Controlled Trials, MEDLINE (PubMed), Embase (Ovid), and Web of Science (from inception to February 1, 2017).

STUDY SELECTION

Randomized controlled trials (RCTs) comparing ultrasound-guided injection with landmark-guided injection in patients with CTS were included.

DATA EXTRACTION

Two authors independently screened abstracts and full texts. The outcomes of interest were Symptom Severity Scale (SSS) and Functional Status Scale (FSS) scores of the Boston Carpal Tunnel Questionnaire and 4 electrodiagnostic parameters, including compound muscle action potential (CMAP), sensory nerve action potential (SNAP), distal motor latency (DML), and distal sensory latency (DSL).

DATA SYNTHESIS

Overall, 569 abstracts were retrieved and checked for eligibility; finally, 3 RCTs were included (181 injected hands). Pooled analysis showed that ultrasound-guided injection was more effective in SSS improvement (mean difference [MD], -.46; 95% confidence interval [CI], -.59 to -.32; P<.00001), whereas no significant difference was observed between the 2 methods in terms of the FSS (MD, -.25; 95% CI, -.56 to .05; P=.10). There were also no statistically significant differences in improvements of CMAP (MD, 1.54; 95% CI, 0.01 to 3.07; P=.05), SNAP (MD, -0.02; 95% CI, -6.27 to 6.23; P>.99), DML (MD, .05; 95% CI, -.30 to .39; P=.80), or DSL (MD, .00; 95% CI, -.65 to .65; P>.99).

CONCLUSIONS

This review suggested that ultrasound-guided injection was more effective than landmark-guided injection in symptom severity improvement in patients with CTS; however, no significant differences were observed in functional status or electrodiagnostic improvements between the 2 methods.

A Randomized Prospective Comparison of Ultrasound-Guided and Landmark-Guided Steroid Injections for Carpal Tunnel Syndrome

PURPOSE

The aim of this study was to compare the clinical and electrodiagnostic efficacy of ultrasound (US)-guided versus landmark (LM)-guided steroid injections in patients with carpal tunnel syndrome (CTS).

METHODS

This randomized clinical trial included 47 patients (60 affected hands) with moderate CTS (30 hands in each group). All clinically suspected patients with CTS who met the inclusion criteria confirmed by electrodiagnostic tests were enrolled. The subjects received 40 mg of methylprednisolone either with the US-guide or the LM-guided injection technique. They were evaluated using the Boston Carpal Tunnel Questionnaire (symptom/function/total) and 6 electrodiagnostic findings at the baseline and 12 weeks after injection.

RESULTS

Symptom severity scores and functional status scores and electrodiagnostic parameters were significantly improved within each group at week 12 after treatment (P < 0.05), except for compound muscle action potential amplitude and motor nerve conduction velocity (P > 0.05). The improvement in symptom severity scores and functional status scores in the US-guided group was more than in the LM-guided group after 12 weeks, but there was no statistically significant difference (P = 0.79 and 0.64). The mean changes in electrodiagnostic parameters were also not different between groups except for the higher sensory nerve action potential amplitude in LM-guided group (P = 0.003).

CONCLUSIONS

Both US-guided and LM-guided steroid injections were effective in reducing the symptoms, improving the function and electrodiagnostic findings of CTS. Although there was better symptomatic improvement with US-guided injections and better increase in sensory nerve action potential amplitude with LM-guided injection, a significant difference was not generally observed between US-guided and LM-guided CTS injections.

Importance of Recognizing Carpal Tunnel Syndrome for Neurosurgeons: A Review

Idiopathic carpal tunnel syndrome (CTS) is a common complaint, reflecting entrapment neuropathy of the upper extremity. CTS produces symptoms similar to those of other conditions, such as cervical spondylosis or ischemic or neoplastic intracranial disease. Because of these overlaps, patients with CTS are often referred to a neurosurgeon. Surgical treatment of CTS was started recently in our department. Through this experience, we realized that neurosurgeons should have an increased awareness of this condition so they can knowledgeably assess patients with a differential diagnosis that includes CTS and cervical spinal and cerebral disease. We conducted a literature review to gain the information needed to summarize current knowledge on the clinical, pathogenetic, and therapeutic aspects of CTS. Because the optimal diagnostic criteria for this disease are still undetermined, its diagnosis is based on the patient’s history and physical examination, which should be confirmed by nerve conduction studies and imaging modalities such as magnetic resonance imaging and ultrasonography. Treatment methods include observation, medication, splinting, steroid injections, and surgical intervention. Understanding the clinical features and pathogenesis of CTS, as well as the therapeutic options available to treat it, is important for neurosurgeons if they are to provide the correct management of patients with this disease.

Exploring the Effectiveness of External Use of Bach Flower Remedies on Carpal Tunnel Syndrome: A Pilot Study

BACKGROUND

A randomized, pilot, placebo-controlled clinical trial was conducted with the aim of evaluating the effectiveness of a cream based on Bach flower remedies (BFR) on symptoms and signs of carpal tunnel syndrome.

METHODS

Forty-three patients with mild to moderate carpal tunnel syndrome during their "waiting" time for surgical option were randomized into 3 parallel groups: Placebo (n = 14), blinded BFR (n = 16), and nonblinded BFR (n = 13). These groups were treated during 21 days with topical placebo or a cream based on BFR.

RESULTS

Significant improvements were observed on self-reported symptom severity and pain intensity favorable to BFR groups with large effect sizes (η2partial > 0.40). In addition, all signs observed during the clinical exam showed significant improvements among the groups as well as symptoms of pain, night pain, and tingling, also with large effect sizes (φ > 0.5). Finally, there were significant differences between the blinded and nonblinded BFR groups for signs and pain registered in clinical exam but not in self-reports.

CONCLUSION

The proposed BFR cream could be an effective intervention in the management of mild and moderate carpal tunnel syndrome, reducing the severity symptoms and providing pain relief.

Pulsed magnetic field versus ultrasound in the treatment of postnatal carpal tunnel syndrome: A randomized controlled trial in the women of an Egyptian population

The aim of this study was to compare the effects of pulsed electromagnetic field versus pulsed ultrasound in treating patients with postnatal carpal tunnel syndrome. The study was a randomized, double-blinded trial. Forty postnatal female patients with idiopathic carpal tunnel syndrome were divided randomly into two equal groups. One group received pulsed electromagnetic field, with nerve and tendon gliding exercises for the wrist, three times per week for four weeks. The other group received pulsed ultrasound and the same wrist exercises. Pain level, sensory and motor distal latencies and conduction velocities of the median nerve, functional status scale and hand grip strength were assessed pre- and post-treatment. There was a significant decrease (P < 0.05) in pain level, sensory and motor distal latencies of the median nerve, and significant increase (P < 0.05) in sensory and motor conduction velocities of the median nerve and hand grip strength in both groups, with a significant difference between the two groups in favour of pulsed electromagnetic field treatment. However, the functional status scale showed intergroup no significant difference (P > 0.05). In conclusion, while the symptoms were alleviated in both groups, pulsed electromagnetic field was more effective than pulsed ultrasound in treating postnatal carpal tunnel syndrome.

Two-point discrimination and kinesthetic sense disorders in productive age individuals with carpal tunnel syndrome

Objectives:

The aim of this study was to evaluate two-point discrimination (2PD) sense and kinesthetic sense dysfunctions in carpal tunnel syndrome (CTS) patients compared with a healthy group.

Methods:

The 2PD sense, muscle force, and kinesthetic differentiation (KD) of strength; the range of motion in radiocarpal articulation; and KD of motion were assessed.

Results:

The 2PD sense assessment showed significantly higher values in all the examined fingers in the CTS group than in those in the healthy group (p<0.01). There was a significant difference in the percentage value of error in KD of pincer and cylindrical grip (p<0.01) as well as in KD of flexion and extension movement in the radiocarpal articulation (p<0.01) between the studied groups.

Conclusions:

There are significant differences in the 2PD sense and KD of strength and movement between CTS patients compared with healthy individuals.

Effectiveness of splinting and splinting plus local steroid injection in severe carpal tunnel syndrome: A Randomized control clinical trial

Background:

The Study aimed to compare the effectiveness of two commonly used conservative treatments, splinting and local steroid injection in improving clinical and nerve conduction findings of the patients with severe carpal tunnel syndrome (CTS).

Materials and Methods:

In this randomized control clinical trial, the patients with severe CTS selected and randomized in two interventional groups. Group A was prescribed to use full time neutral wrist splint and group B was injected with 40 mg Depo-Medrol and prescribed to use the full time neutral wrist splint for 12 weeks. Clinical and nerve conduction findings of the patients was evaluated at baseline, 4 and 12 weeks after interventions.

Results:

Twenty-two and 21 patients were allocated in group A and B, respectively. Mean of clinical symptoms and functional status scores, nerve conduction variables and patients’ satisfaction score were not significant between group at baseline and 4 and 12 weeks after intervention. Within the group comparison, there was significant improvement in the patients’ satisfaction, clinical and nerve conduction items between the baseline level and 4 weeks after intervention and between the baseline and 12 weeks after intervention (P < 0.01). The difference was significant for functional status score between 4 and 12 weeks after intervention in group B (P = 0.02).

Conclusion:

considering some findings regarding the superior effect of splinting plus local steroid injection on functional status scale and median nerve distal motor latency, it seems that using combination therapy could be more effective for long-term period specially in the field of functional improvement of CTS.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical effectiveness of acupuncture for carpal tunnel syndrome

Acupuncture and electroacupuncture treatments of symptomatic carpal tunnel syndrome (CTS) may improve symptoms and aid nerve repair as well as improve sensory and motor functions. However, limited evidence is available regarding the effects of these treatments based on comprehensive evaluation methods. This research completed the treatment and evaluation of 26 patients with confirmed CTS. Participants were divided into two treatment groups based on a modified neurophysiological grading scale. Of the total number of participants, 15 received acupuncture and 11 received electroacupuncture on both upper limbs. Acupoints were PC-7 (Daling) and PC-6 (Neiguan) along the pericardial meridian compatible with the median nerve tract. The treatment program consisted of 24 sessions of 15 min duration over 6 weeks. After electroacupuncture treatments, symptom severity was evaluated using the short clinical questionnaire by Lo and Chiang, which indicated improvements in the respective symptom severity score. After the acupuncture treatment, grip strength in the major symptomatic side in CTS patients could be significantly increased. Electrophysiology evaluation likewise indicated a significant increase in the distal median motor amplitude of the palm-wrist segment. In addition, Tinel's sign significantly decreased in the major symptomatic side. Our findings indicated that electroacupuncture could improve symptomatology, while acupuncture could exert positive therapeutic effects for CTS patients, as evidenced by improved symptomatology, grip strength, electrophysiological function, and physical provocation sign.

A handy review of carpal tunnel syndrome: From anatomy to diagnosis and treatment

Carpal tunnel syndrome (CTS) is the most commonly diagnosed disabling condition of the upper extremities. It is the most commonly known and prevalent type of peripheral entrapment neuropathy that accounts for about 90% of all entrapment neuropathies. This review aims to provide an outline of CTS by considering anatomy, pathophysiology, clinical manifestation, diagnostic modalities and management of this common condition, with an emphasis on the diagnostic imaging evaluation.

Ergonomic Design of a Computer Mouse for Clients With Wrist Splints

OBJECTIVE. We explored effects of cutaneous feedback and hump position on efficiency and comfort in mouse use with a splint. We also analyzed the relationship between anthropometric measurements (width of hand and length of hand, palm, and index) and the task performance.

METHOD. Thirty participants performed a computer task with two forms of mice (front hump and rear hump) and two kinds of wrist splints (dorsal and volar). Movement time and satisfaction scores were recorded.

RESULTS. No interaction effect (Hump Position × Splint Type) was found on movement time. Movement time was shorter for rear-hump mouse users than for front-hump mouse users. Movement time was also shorter for wearers of dorsal wrist splints than for wearers of volar wrist splints. Limited differences existed in the satisfaction scores. Participants with a longer index finger had shorter movement time.

CONCLUSION. Both dorsal wrist splints and rear-hump mice are recommended. Length of index finger positively correlated with task performance.

Preoperative corticosteroid injections are associated with worse long-term outcome of surgical carpal tunnel release

BACKGROUND AND PURPOSE

Failed closed treatment of carpal tunnel syndrome (CTS) is often followed by surgery. We investigated whether preoperative steroid injections could have a negative effect on the long-term outcome of the operation.

PATIENTS AND METHODS

174 hands (164 patients) were operated on by a single surgeon at Tartu University Hospital in 2005. The patients were interviewed by telephone 5-6 years after the operation. Self-reported data were gathered retrospectively concerning the number of steroid injections received before the surgery and the perceived regression of symptoms (on a 100-point numeric rating scale) at the time of interview. The patients were also asked about the presence of specific symptoms of CTS if regression of their symptoms had not been complete.

RESULTS

93 of the 174 hands had complete regression of symptoms. Each additional injection was associated with an increased risk of occurrence of pain (RR = 1.1, 95% CI: 1.02-1-2), paresthesiae (RR = 1.1, CI: 1.1-1.2), and nocturnal awakenings (RR = 1.2, CI: 1.1-1.3). There was a weak association between the number of injections and the score given to regression of symptoms.

INTERPRETATION

This is the first study to indicate that patients who received a greater number of local steroid injections preoperatively were more likely to have postoperative complaints associated with CTS.