Effects of placebo-controlled continuous and pulsed ultrasound treatments on carpal tunnel syndrome: a randomized trial

Efficiency of therapeutic underwater ultrasound therapy in mild-to-moderate carpal tunnel syndrome: A randomized sham-controlled study

Objectives

This study aimed to evaluate the efficiency of therapeutic pulsed ultrasound (US) applied underwater in mild-to-moderate carpal tunnel syndrome (CTS).

Patients and methods

This randomized, placebo-controlled study included 75 patients (114 hands; 7 males, 68 females; mean age: 46.7±9.9 years; range, 24 to 64 years) diagnosed with CTS through clinical evaluation and electroneuromyography (ENMG) results between March 2012 and January 2013. Patients were randomized into three groups. Group 1 received underwater pulsed US, Group 2 received sham US, and Group 3 was the control group. All groups were given night splints. Patients were evaluated at baseline, at the end of treatment (two weeks), and 12 weeks after the treatment using clinical examination tests (Tinel, Phalen, and hand elevation test), hand grip strength, Visual Analog Scale (VAS) for pain, Pain Quality Assessment Scale (PQAS), and ENMG.

Results

In all groups, a significant improvement was detected in the clinical assessment parameters, including the pain VAS, PQAS scores, physical examination outcomes, and hand grip strength. The decrease in VAS score and PQAS was found to be superior in the pulsed US group at both two weeks after the treatment and at the 12th week after the treatment compared to the sham US and control groups (p<0.001). Improvement in ENMG parameters, such as median motor latency, median sensorial velocity, and median sensory latency, was observed only in the underwater pulsed US group (p<0.001).

Conclusion

Therapeutic underwater pulsed US is an effective, safe, and easy-to-apply treatment option in the conservative treatment of mild-to-moderate CTS.

Comparison of 4 weeks of cupping and Kinesio-taping on clinical and ultrasound outcomes of carpal tunnel syndrome during pregnancy

OBJECTIVE

To explore effect of cupping and Kinesio-taping techniques on clinical and ultrasound outcomes of carpal tunnel syndrome (CTS) during pregnancy.

METHODS

Thirty pregnant women suffering from CTS were randomly assigned into Kinesio-taping (n = 15) and cupping (n = 15) groups. In Kinesio-taping group, individuals underwent Kinesio-taping for three days, one day with no treatment, and three days with Kinesio-taping, continuing this procedure for four weeks. In cupping group, cupping was moved for 5 min with pressure of 50 mm-Hg on the carpal tunnel area. This procedure continued longitudinally in forearm area for 2 min. The therapeutic intervention of cupping group continued with eight sessions, two days a week for 4 weeks. Ultrasound outcomes including median nerve cross-sectional area through ultrasonography, and clinical outcomes including pain through visual analog scale and severity of symptoms and functional status through Boston questionnaire were measured in both groups before and after therapeutic program.

RESULTS

In both groups, a significant reduction was observed in all variables after treatment compared to pre-treatment (P < 0.001). In inter-group comparison, a significant improvement was found in outcomes of Boston questionnaire and ultrasound results about median nerve cross-sectional area at pisiform and hook of hamate in cupping group compared to Kinesio-taping at end of four weeks (P < 0.001).

CONCLUSION

Both cupping and Kinesio-taping improved clinical and ultrasound outcomes of CTS. However, efficacy of cupping compared to Kinesio-taping was better in improvement of median nerve cross-sectional area at hamate hook and pisiform levels, symptoms severity scale, and functional status scale, which makes the results clinically more applicable.

Understanding carpal tunnel syndrome

ABSTRACT

Carpal tunnel syndrome (CTS) is an entrapment neuropathy affecting the median nerve. Prevalence is estimated at 4% to 5% of the population. A solid understanding of the anatomy, presentation, and diagnostics is key to efficient diagnosis and appropriate referral. Both surgical and nonsurgical interventions have led to improved clinical outcomes. Clinicians who have an in-depth knowledge of CTS symptoms and treatment options can prepare patients and streamline referrals for improved patient outcomes.

A randomized-controlled clinical trial comparing the effects of steroid phonophoresis and therapeutic ultrasound in carpal tunnel syndrome

Objectives

In this study, we aimed to compare the efficacy of ultrasonography (US) and steroid phonophoresis (PH) treatments in patients with idiopathic carpal tunnel syndrome (CTS).

Patients and methods

Between January 2013 and May 2015, a total of 46 hands of 27 patients (5 males, 22 females; mean age: 47.3+13.7 years; range, 23 to 67 years) with idiopathic mild/moderate CTS without tenor atrophy or spontaneous activity in abductor pollicis brevis were included. The patients were randomly divided into three groups. The first group was ultrasound (US) group, the second group was PH group, and the third group was placebo US group. Continuous US with a frequency of 1 MHz, an intensity of 1.0 W/cm² was used in the US and the PH groups. The PH group received 0.1% dexamethasone. Placebo group received a frequency of 0 MHz, an intensity of 0 W/cm² US. Treatments were administered for five days a week, a total of 10 sessions. All patients also wore night splints during treatment. The Visual Analog Scale (VAS), Boston Carpal Tunnel Questionnaire consisting of two parts, namely the Symptom Severity Scale and Functional Status Scale), grip strength, and electroneurophysiological evaluations were compared before the treatment, after the treatment, and three months later.

Results

All clinical parameters improved in all groups after treatment and at three months, except for the grip strength. Recovery in the sensory nerve conduction velocity between palm and wrist was seen in US group at three months after the treatment; however, recovery in the sensory nerve distal latency between the second finger and palm was seen in PH and placebo groups after treatment and at three months after the treatment.

Conclusion

The results of this study suggest that splinting therapy combined with steroid PH, placebo or continuous US is effective for both clinical and electroneurophysiological improvement; however, electroneurophysiological improvement is limited.

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.

Ultrasound improves motor distal latency on patients with carpal tunnel syndrome: systematic review and meta-analysis

INTRODUCTION

Is the application of ultrasound effective on pain, the severity of the symptoms, physical function, strength, and neurophysiological parameters of the median nerve conduction in patients with carpal tunnel syndrome?

EVIDENCE ACQUISITION

A systematic review and meta-analysis of randomized controlled trials was performed by using a structured search strategy in Scopus, CINAHL, Web of Science and PEDro databases. All the primary studies included samples with carpal tunnel syndrome treated by: ultrasound versus no treatment, therapeutic ultrasound versus sham ultrasound, ultrasound and usual care versus usual care, or ultrasound and other intervention versus the same intervention. The outcomes measures registered were pain, severity of symptoms, function, strength, and neurophysiological parameters (motor distal latency and sensory distal latency) of the median nerve. Methodological quality was evaluated by PEdro Scale.

EVIDENCE SYNTHESIS

Ten clinical trials met the inclusion criteria for the systematic review. Eight trials were meta-analyzed, which included a total of 2069 patients with carpal tunnel syndrome. The methodological quality of the included studies ranged among limited (5 trials), moderate (3 trials), and high (2 trials). In one of the electrophysiological parameters (motor distal latency), a significant difference between groups after the use of ultrasound was observed (MD=-0.10; fixed 95% CI=-0.20, -0.01; P=0.04). No significant differences between groups were observed at post-treatment for pain (P=0.29), severity of symptoms (P=0.99), function (P=0.54), strength (P=0.27) and for the rest of the electrophysiological parameters evaluated (P>0.05).

CONCLUSIONS

The use of ultrasound on patients with carpal tunnel syndrome seems to improve motor distal latency. This finding implies a partial improvement at the neurophysiological level, representing a reduction in the grade of clinical severity. Additional clinical trials with a high methodological quality are needed to investigate the doses at which ultrasound are most effective.

Effectiveness of electrophysical modalities in the sensorimotor rehabilitation of radial, ulnar, and median neuropathies: A meta-analysis

INTRODUCTION

People with ulnar, radial or median nerve injuries can present significant impairment of their sensory and motor functions. The prescribed treatment for these conditions often includes electrophysical therapies, whose effectiveness in improving symptoms and function is a source of debate. Therefore, this systematic review aims to provide an integrative overview of the efficacy of these modalities in sensorimotor rehabilitation compared to placebo, manual therapy, or between them.

METHODS

We conducted a systematic review according to PRISMA guidelines. We perform a literature review in the following databases: Biomed Central, Ebscohost, Lilacs, Ovid, PEDro, Sage, Scopus, Science Direct, Semantic Scholar, Taylor & Francis, and Web of Science, for the period 1980-2020. We include studies that discussed the sensorimotor rehabilitation of people with non-degenerative ulnar, radial, or median nerve injury. We assessed the quality of the included studies using the Risk of Bias Tool described in the Cochrane Handbook of Systematic Reviews of Interventions and the risk of bias across studies with the GRADE approach described in the GRADE Handbook.

RESULTS

Thirty-eight studies were included in the systematic review and 34 in the meta-analysis. The overall quality of evidence was rated as low or very low according to GRADE criteria. Low-level laser therapy and ultrasound showed favourable results in improving symptom severity and functional status compared to manual therapy. In addition, the low level laser showed improvements in pinch strength compared to placebo and pain (VAS) compared to manual therapy. Splints showed superior results to electrophysical modalities. The clinical significance of the results was assessed by effect size estimation and comparison with the minimum clinically important difference (MCID).

CONCLUSIONS

We found favourable results in pain relief, improvement of symptoms, functional status, and neurophysiological parameters for some electrophysical modalities, mainly when applied with a splint. Our results coincide with those obtained in some meta-analyses. However, none of these can be considered clinically significant.

TRIAL REGISTRATION

PROSPERO registration number CRD42020168792; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=168792.

Non-operative Treatment of Carpal Tunnel Syndrome

PURPOSE OF REVIEW

To determine the current evidence for various non-operative therapies in the treatment of carpal tunnel syndrome RECENT FINDINGS: Multiple non-operative treatment modalities exist in the treatment of mild to moderate carpal tunnel syndrome. While certain modalities such as splinting and corticosteroid injections have moderate- to high-quality evidence to support use, other less commonly used treatments have fewer therapeutic indications in the current literature. Healthcare providers should be able to initiate the appropriate diagnostic evaluation and assess the utility of non-operative therapies in the treatment of carpal tunnel syndrome. Moreover, healthcare providers should also be able to understand the evidence behind each treatment and the indications for surgical intervention.

Ultrasound therapy adds no benefit to splinting in carpal tunnel syndrome

INTRODUCTION

Therapeutic ultrasound has been suggested as a treatment for carpal tunnel syndrome (CTS), but existing trial evidence is of poor quality and inconclusive.

METHODS

We conducted a randomized, controlled trial of therapeutic ultrasound in mild to moderate CTS. Forty patients were treated with wrist splints plus either real or sham therapeutic ultrasound and followed for 1 year posttreatment. The primary outcome was change in symptom severity scale score. Secondary outcomes were functional status scale score, nerve conduction studies, and ultrasound imaging of the median nerve.

RESULTS

Both groups showed significant clinical and neurophysiological improvement at 6 and 12 months compared with baseline. There were no significant differences between groups at any time. In a multivariate analysis, the only independently significant predictors of the primary outcome were pretreatment symptom severity and additional treatments during follow-up.

DISCUSSION

We found no clinically significant benefit from ultrasound treatment for CTS.

Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome

The Academy of Orthopaedic Physical Therapy and the Academy of Hand and Upper Extremity Physical Therapy have an ongoing effort to create evidence-based clinical practice guidelines (CPGs) for orthopaedic and sports physical therapy management and prevention of musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability and Health (ICF). This particular guideline focuses on hand pain and sensory deficits in carpal tunnel syndrome. J Orthop Sports Phys Ther 2019;49(5):CPG1-CPG85. doi:10.2519/jospt.2019.0301.

Ultrasonographic imaging of the effects of continuous, pulsed or sham ultrasound treatments on carpal tunnel syndrome: A randomized controlled study

BACKGROUND

Clinical and electrophysiological effects of therapeutic ultrasound (US) were researched in many studies on patients with CTS with conflicting results.

OBJECTIVE

To assess the effects of continuous and pulsed US treatments by ultrasonographic imaging in addition to clinical and electrophysilogical parameters in patients with carpal tunnel syndrome (CTS).

METHOD

Fifty-four patients with idiopathic CTS were randomly divided into three groups. All patients used night splints for two weeks. In addition to splint therapy, continuous, pulsed or sham US treatments were applied to patients 10 min/session, 5 sessions/week for two weeks. Clinical situation (pain, hand function, strength), electrophysiological studies (motor distal latency, MDL, sensorial distal latency, SDL), and ultrasonographic area measurements of median nerve were evaluated. All evaluations were applied at pretreatment (baseline), posttreatment (2nd week) and in the 6th week.

RESULTS

Whereas significant differences were detected for clinical, functional and ultrasonographic imaging findings in each group in the 2nd week and 6th week compared to baseline (p< 0.0167 for both), no electrophysiological improvements were detected in pulsed-US (p> 0.0167) and only improvement for SDL in sham US group in the 2nd week evaluation (p< 0.0167).

CONCLUSION

According to the results of this study, continuous, pulsed or sham US treatments combined with splinting had similar effects on clinical, electrophysiological and ultrasonographic imaging improvements. Additionally, ultrasonographic imaging may be a preferable objective evaluation tool to prove the early posttreatment clinical improvements when electrophysiological changes could not be detected.

Efficacy of paraffin wax bath for carpal tunnel syndrome: a randomized comparative study

Carpal tunnel syndrome (CTS) is the most frequently diagnosed neuropathy of upper extremity entrapment neuropathies. We aimed to investigate the effectiveness of paraffin therapy in patients with CTS. Seventy patients diagnosed with mild or moderate CTS were randomly divided into two groups as splint treatment (during the night and day time as much as possible for 3 weeks) alone and splint (during the night and day time as much as possible for 3 weeks) + paraffin treatment (five consecutive days a week for 3 weeks). Clinical and electrophysiological assessments were performed before and 3 weeks after treatment. The patients were assessed by using visual analog scale (VAS) for pain, electroneuromyography (ENMG), and Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ). The significant improvement was found in VAS scores in both groups when compared with pretreatment values (p < 0.05). There was no significant improvement in functional capacity score (p > 0.05), whereas a significant improvement was noted in the BCTQ symptom severity scale score in the splint group (p < 0.05). Significant improvements were demonstrated in both scorers in the combined treatment group. Similarly, significant improvements were found in the combined treatment group in terms of motor and sensory distal latency, sensory amplitude, and median sensory nerve velocity (p < 0.05). There was no significant change in electrophysiologic parameters in the splint group (p > 0.05), and the difference in these parameters between the groups was statistically significant (p < 0.05). In conclusion, using splinting alone in patients with CTS is an effective treatment for reducing symptoms in the early stages. Paraffin treatment with splint increases the recovery in functional and electrophysiological parameters.

Conservative therapeutic management of carpal tunnel syndrome

ABSTRACT Carpal tunnel syndrome is the most prevalent nerve compression and can be clinically or surgically treated. In most cases, the first therapeutic alternative is conservative treatment but there is still much controversy regarding the most effective modality of this treatment. In this study, we critically evaluated the options of conservative treatment for carpal tunnel syndrome, aiming to guide the reader through the conventional options used in this therapy.

Carpal Tunnel Syndrome: Effectiveness of Physical Therapy and Electrophysical Modalities. An Updated Systematic Review of Randomized Controlled Trials

OBJECTIVE

To review scientific literature studying the effectiveness of physical therapy and electrophysical modalities for carpal tunnel syndrome (CTS).

DATA SOURCES

The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database.

STUDY SELECTION

Two reviewers independently applied the inclusion criteria to select potential eligible studies.

DATA EXTRACTION

Two reviewers independently extracted the data and assessed the methodologic quality using the Cochrane Risk of Bias Tool.

DATA SYNTHESIS

A best-evidence synthesis was performed to summarize the results of the included studies (2 reviews and 22 randomized controlled trials [RCTs]). For physical therapy, moderate evidence was found for myofascial massage therapy versus ischemic compression on latent, or active, trigger points or low-level laser therapy in the short term. For several electrophysical modalities, moderate evidence was found in the short term (ultrasound vs placebo, ultrasound as single intervention vs other nonsurgical interventions, ultrasound vs corticosteroid injection plus a neutral wrist splint, local microwave hyperthermia vs placebo, iontophoresis vs phonophoresis, pulsed radiofrequency added to wrist splint, continuous vs pulsed vs placebo shortwave diathermy, and interferential current vs transcutaneous electrical nerve stimulation vs a night-only wrist splint). In the midterm, moderate evidence was found in favor of radial extracorporeal shockwave therapy (ESWT) added to a neutral wrist splint, in favor of ESWT versus ultrasound, or cryo-ultrasound, and in favor of ultrasound versus placebo. For all other interventions studied, only limited, conflicting, or no evidence was found. No RCTs investigating the long-term effects of physical therapy and electrophysical modalities were found. Because of heterogeneity in the treatment parameters used in the included RCTs, optimal treatment parameters could not be identified.

CONCLUSIONS

Moderate evidence was found for several physical therapy and electrophysical modalities for CTS in the short term and midterm. Future studies should concentrate on long-term effects and which treatment parameters of physical therapy and electrophysical modalities are most effective for CTS.

Efficacy of Manual Therapy Including Neurodynamic Techniques for the Treatment of Carpal Tunnel Syndrome: A Randomized Controlled Trial

OBJECTIVE

The purpose of this randomized trial was to compare the efficacy of manual therapy, including the use of neurodynamic techniques, with electrophysical modalities on patients with mild and moderate carpal tunnel syndrome (CTS).

METHODS

The study included 140 CTS patients who were randomly assigned to the manual therapy (MT) group, which included the use of neurodynamic techniques, functional massage, and carpal bone mobilizations techniques, or to the electrophysical modalities (EM) group, which included laser and ultrasound therapy. Nerve conduction, pain severity, symptom severity, and functional status measured by the Boston Carpal Tunnel Questionnaire were assessed before and after treatment. Therapy was conducted twice weekly and both groups received 20 therapy sessions.

RESULTS

A baseline assessment revealed group differences in sensory conduction of the median nerve (P < .01) but not in motor conduction (P = .82). Four weeks after the last treatment procedure, nerve conduction was examined again. In the MT group, median nerve sensory conduction velocity increased by 34% and motor conduction velocity by 6% (in both cases, P < .01). There was no change in median nerve sensory and motor conduction velocities in the EM. Distal motor latency was decreased (P < .01) in both groups. A baseline assessment revealed no group differences in pain severity, symptom severity, or functional status. Immediately after therapy, analysis of variance revealed group differences in pain severity (P < .01), with a reduction in pain in both groups (MT: 290%, P < .01; EM: 47%, P < .01). There were group differences in symptom severity (P < .01) and function (P < .01) on the Boston Carpal Tunnel Questionnaire. Both groups had an improvement in functional status (MT: 47%, P < .01; EM: 9%, P < .01) and a reduction in subjective CTS symptoms (MT: 67%, P < .01; EM: 15%, P < .01).

CONCLUSION

Both therapies had a positive effect on nerve conduction, pain reduction, functional status, and subjective symptoms in individuals with CTS. However, the results regarding pain reduction, subjective symptoms, and functional status were better in the MT group.

Carpal tunnel syndrome: clinical features, diagnosis, and management

Carpal tunnel syndrome is the most common peripheral nerve entrapment syndrome worldwide. The clinical symptoms and physical examination findings in patients with this syndrome are recognised widely and various treatments exist, including non-surgical and surgical options. Despite these advantages, there is a paucity of evidence about the best approaches for assessment of carpal tunnel syndrome and to guide treatment decisions. More objective methods for assessment, including electrodiagnostic testing and nerve imaging, provide additional information about the extent of axonal involvement and structural change, but their exact benefit to patients is unknown. Although the best means of integrating clinical, functional, and anatomical information for selecting treatment choices has not yet been identified, patients can be diagnosed quickly and respond well to treatment. The high prevalence of carpal tunnel syndrome, its effects on quality of life, and the cost that disease burden generates to health systems make it important to identify the research priorities that will be resolved in clinical trials.

Clinical and electrophysiological evaluation of neutral wrist nocturnal splinting in patients with carpal tunnel syndrome

[Purpose] To prospectively assess the effectiveness of neutral wrist nocturnal splinting in patients with carpal tunnel syndrome (CTS) by using clinical scores and nerve conduction studies (NCS). [Subjects and Methods] Forty-one patients enrolled in the study were clinically evaluated by a symptom severity scale (SSS) and functional status scale (FSS), and were electrophysiologically evaluated by conventional NCS; distal motor latency (DML), sensory conduction velocity (SCV), and difference in sensory latency between the median and ulnar nerves (ΔDSL) were measured. Subjects were treated with wrist splinting. Patients who showed no improvement in symptoms were treated with other conservative treatments, the remaining patients continued to wear splints. SSS, FSS, and NCS were evaluated after splinting as well. [Results] The follow-up was completed in 20 patients (31 wrists) with splinting. SSS and FSS decreased, the DML shortened and ΔDSL decreased significantly after splinting for 3.03 ± 1.16 months. There were significant correlations between SSS and DML, SCV of wrist digit 2, and SCV of wrist digit 4. No correlations were found between SSS and ΔDSL, and FSS and the parameters of NCS. [Conclusion] Neutral wrist nocturnal splinting is effective in at least short term for CTS patients. There is a weak correlation between clinical scores and NCS, which suggests that both approaches should be used to effectively assess the therapeutic effect of CTS treatment.