Summary:  While the preferred approach to carpal tunnel has been surgery, almost no information on the long term outcomes of surgical versus conservative treatment exists.  Given the short duration of surgical follow ups (3 months) and troubling reports of long term side effects, carpal tunnel surgery should only follow conservative treatment. 

Cochrane Database Syst Rev. 2008 Oct 8;(4):CD001552. Links

Update of:

Cochrane Database Syst Rev. 2003;(3):CD001552.

Surgical versus non-surgical treatment for carpal tunnel syndrome.Verdugo RJ, Salinas RA, Castillo JL, Cea JG.

Department of Neurology, Faculty of Medicine, Universidad de Chile, Santiago, Region Metropolitana of Santiago, Chile. rverdugo@med.uchile.cl

BACKGROUND: Carpal tunnel syndrome results from entrapment of the median nerve in the wrist. Common symptoms are tingling, numbness, and pain in the hand that may radiate to the forearm or shoulder. Most symptomatic cases are treated non-surgically. OBJECTIVES: The objective is to compare the efficacy of surgical treatment of carpal tunnel syndrome with non-surgical treatment. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Register (January 2008), MEDLINE (January 1966 to January 2008), EMBASE (January 1980 to January 2008) and LILACS (January 1982 to January 2008). We checked bibliographies in papers and contacted authors for information about other published or unpublished studies. SELECTION CRITERIA: We included all randomised and quasi-randomised controlled trials comparing any surgical and any non-surgical therapies. DATA COLLECTION AND ANALYSIS: Two authors independently assessed the eligibility of the trials. MAIN RESULTS: In this update we found four randomised controlled trials involving 317 participants in total. Three of them including 295 participants, 148 allocated to surgery and 147 to non-surgical treatment reported information on our primary outcome (improvement at three months of follow-up). The pooled estimate favoured surgery (RR 1.23, 95% CI 1.04 to 1.46). Two trials including 245 participants described outcome at six month follow-up, also favouring surgery (RR 1.19, 95% CI 1.02 to 1.39).Two trials reported clinical improvement at one year follow-up. They included 198 patients favouring surgery (RR 1.27, 95% CI 1.05 to 1.53). The only trial describing changes in neurophysiological parameters in both groups also favoured surgery (RR 1.44, 95% CI 1.05 to 1.97). Two trials described need for surgery during follow-up, including 198 patients. The pooled estimate for this outcome indicates that a significant proportion of people treated medically will require surgery while the risk of re-operation in surgically treated people is low (RR 0.04 favouring surgery, 95% CI 0.01 to 0.17). Complications of surgery and medical treatment were described by two trials with 226 participants. Although the incidence of complications was high in both groups, they were significantly more common in the surgical arm (RR 1.38, 95% CI 1.08 to 1.76). AUTHORS' CONCLUSIONS: Surgical treatment of carpal tunnel syndrome relieves symptoms significantly better than splinting. Further research is needed to discover whether this conclusion applies to people with mild symptoms and whether surgical treatment is better than steroid injection.

PMID: 18843618

Muscle Nerve. 2008 Nov;38(5):1443-6. Links

Long-term complications of open carpal tunnel release.Boya H, Ozcan O, Oztekin HH.

Department of Orthopaedics and Traumatology, Faculty of Medicine, Afyon Kocatepe University, Afyonkarahisar, Turkey. hakanboya@yahoo.com

Fifty patients who underwent open carpal tunnel release (OCTR) surgery at least 12 months earlier for carpal tunnel syndrome were reviewed, focusing on scar tenderness, pillar pain, and symptoms of neuroma. A total of 55 hands were studied. At an average of 20.2 months of follow-up, 5.5% had Tinel's sign, 7.3% had scar tenderness, 12.7% had pillar pain, and 18% had burning discomfort. Pillar pain was elicited in a much higher fraction of patients by using the "table test" (provocation of pillar pain by having the patient lean with his/her weight on the hands placed on the edge of a table), even when traditional tests were negative. Symptoms and signs are present in a substantial number of patients after OCTR, even after almost 2 years of follow-up. Patients should be informed of the incidence of long-term symptoms and signs after OCTR surgery.

PMID: 18949783

J Altern Complement Med. 2008 Apr;14(3):259-67. Links

Comparison of a targeted and general massage protocol on strength, function, and symptoms associated with carpal tunnel syndrome: a randomized pilot study.Moraska A, Chandler C, Edmiston-Schaetzel A, Franklin G, Calenda EL, Enebo B.

School of Nursing, University of Colorado at Denver and Health Sciences Center, Denver, CO 80262, USA. moraska@alum.rpi.edu

OBJECTIVE: Carpal tunnel syndrome (CTS) is a major, costly public health issue that could be dramatically affected by the identification of additional conservative care treatment options. Our study aimed to evaluate the effectiveness of two distinct massage therapy protocols on strength, function, and symptoms associated with CTS. DESIGN: This was a randomized pilot study design with double pre-tests and subjects blinded to treatment group assignment. SETTING/LOCATION: The setting for this study was a wellness clinic at a teaching institution in the United States. SUBJECTS: Twenty-seven (27) subjects with a clinical diagnosis of CTS were included in the study. INTERVENTIONS: Subjects were randomly assigned to receive 6 weeks of twice-weekly massage consisting of either a general (GM) or CTS-targeted (TM) massage treatment program. OUTCOME MEASURES: Dependent variables included hand grip and key pinch dynamometers, Levine Symptom and Function evaluations, and the Grooved Pegboard test. Evaluations were conducted twice during baseline, 2 days after the 7th and 11th massages, and at a follow-up visit 4 weeks after the 12th massage treatment. RESULTS: A main effect of time was noted on all outcome measures across the study time frame (p < 0.001); improvements persist at least 4 weeks post-treatment. Comparatively, TM resulted in greater gains in grip strength than GM (p = 0.04), with a 17.3% increase over baseline (p < 0.001), but only a 4.8% gain for the GM group (p = 0.21). Significant improvement in grip strength was observed following the 7th massage. No other comparisons between treatment groups attained statistical significance. CONCLUSIONS: Both GM and TM treatments resulted in an improvement of subjective measures associated with CTS, but improvement in grip strength was only detected with the TM protocol. Massage therapy may be a practical conservative intervention for compression neuropathies, such as CTS, although additional research is needed.

PMID: 18370581

Eura Medicophys. 2007 Sep;43(3):391-405. Links

Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults. A Cochrane systematic review.Verhagen AP, Karels C, Bierma-Zeinstra SM, Feleus A, Dahaghin S, Burdorf A, De Vet HC, Koes BW.

Erasmus MC, University Mediacal Center Rotterdam, PO Box 1738, 3000 DR Rotterdam, Netherlands. a.verhagen@erasmusmc.nl

BACKGROUND: Conservative interventions such as physiotherapy and ergonomic adjustments (such as keyboard adjustments or ergonomic advice) play a major role in the treatment of most work-related complaints of the arm, neck or shoulder (CANS). Objectives. This systematic review aims to determine whether conservative interventions have a significant impact on outcomes for work-related CANS in adults. Search strategy. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2005) and Cochrane Rehabilitation and Related Therapies Field Specialised Register (March 2005), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2005), PubMed, EMBASE, CINAHL, AMED and reference lists of articles. The date of the last search was March 2005. No language restrictions were applied. Selection criteria. We included randomised controlled trials and concurrent controlled trials studying conservative interventions (e.g. exercises, relaxation, physical applications, biofeedback, myofeedback and work-place adjustments) for adults suffering CANS. Data collection and analysis. Two authors independently selected trials from the search yield, assessed the methodological quality using the Delphi list, and extracted relevant data. We pooled data or, in the event of clinical heterogeneity or lack of data, we used a rating system to assess levels of evidence. Main RESULTS: For this update we included six additional studies; twenty-one trials in total. Seventeen trials included people with chronic nonspecific neck or shoulder complaints, or nonspecific upper extremity disorders. Over twenty-five interventions were evaluated; six main subgroups of interventions could be determined: exercises, manual therapy, massage, ergonomics, energised splint and individual treatment versus group therapy. Overall, the quality of the studies was poor. In 14 studies a form of exercise was evaluated, and contrary to the previous review we now found limited evidence about the effectiveness of exercises when compared to massage and conflicting evidence when exercises are compared to no treatment. In this update there is limited evidence for adding breaks during computer work; massage as add-on treatment on manual therapy, manual therapy as add-on treatment on exercises; and some keyboard designs when compared to other keyboards or placebo in participants with carpal tunnel syndrome. CONCLUSIONS: There is limited evidence for the effectiveness of keyboards with an alternative force-displacement of the keys or an alternative geometry, and limited evidence for the effectiveness of exercises compared to massage, breaks during computer work compared to no breaks; massage as an add-on treatment to manual therapy, and manual therapy as an add-on treatment to exercises.

PMID: 17921965

Clin Rehabil. 2007 Apr;21(4):299-314. Links

A systematic review of conservative treatment of carpal tunnel syndrome.Piazzini DB, Aprile I, Ferrara PE, Bertolini C, Tonali P, Maggi L, Rabini A, Piantelli S, Padua L.

Department of Physical Medicine and Rehabilitation, Catholic University, Rome, Italy.

OBJECTIVE: To assess the effectiveness of conservative therapy in carpal tunnel syndrome. DATA SOURCES: A computer-aided search of MEDLINE and the Cochrane Collaboration was conducted for randomized controlled trials (RCTs) from January 1985 to May 2006. REVIEW METHODS: RCTs were included if: (1) the patients, with clinically and electrophysiologically confirmed carpal tunnel syndrome, had not previously undergone surgical release, (2) the efficacy of one or more conservative treatment options was evaluated, (3) the study was designed as a randomized controlled trial. Two reviewers independently selected the studies and performed data extraction using a standardized form. In order to assess the methodological quality, the criteria list of the Cochrane Back Review Group for systematic reviews was applied. The different treatment methods were grouped (local injections, oral therapies, physical therapies, therapeutic exercises and splints). RESULTS: Thirty-three RCTs were included in the review. The studies were analysed to determine the strength of the available evidence for the efficacy of the treatment. Our review shows that: (1) locally injected steroids produce a significant but temporary improvement, (2) vitamin B6 is ineffective, (3) steroids are better than non-steroidal anti-inflammatory drugs (NSAIDs) and diuretics, but they can produce side-effects, (4) ultrasound is effective while laser therapy shows variable results, (5) exercise therapy is not effective, (6) splints are effective, especially if used full-time. CONCLUSION: There is: (1) strong evidence (level 1) on efficacy of local and oral steroids; (2) moderate evidence (level 2) that vitamin B6 is ineffective and splints are effective and (3) limited or conflicting evidence (level 3) that NSAIDs, diuretics, yoga, laser and ultrasound are effective whereas exercise therapy and botulinum toxin B injection are ineffective.

PMID: 17613571

J Am Coll Nutr. 1994 Apr;13(2):118-26.        Related Articles, Links

Vitamin supplements: current controversies.

Reynolds RD.

Department of Nutrition and Medical Dietetics, University of Illinois at Chicago 60612.

Supplemental use of vitamins to prevent disease constitutes a major commercial enterprise in the United States. The efficacy of such use, or even the need for intakes above that which can be supplied by means of diet alone, has been the source of considerable controversy in the medical and scientific fields. Recently published data have given strong support to several of the claims for major benefits of disease prevention, including that of cancer, cardiovascular disease, carpal tunnel syndrome, and neural tube defects, to name just a few. The purported benefits for supplemental vitamin usage are discussed for these diseases, along with a call for a re-evaluation of the underlying philosophy of the Recommended Dietary Allowances, or consideration of their abolition, based on newly emerging data.

Publication Types:

•              Review

•              Review, Tutorial

PMID: 8006292 [PubMed - indexed for MEDLINE]

J Nutr Sci Vitaminol (Tokyo). 1981;27(3):193-7.         Related Articles, Links

Distribution of vitamin B6 deficiency in university students.

Shizukuishi S, Nishii S, Folkers K.

The basal specific activities (S.A.; mumol of pyruvate/hr/10(8) erythrocytes) and the % deficiencies of activity of the glutamic oxaloacetic transaminase of the erythrocytes (EGOT) of 174 university students was 0.28 +/- 0.05 and 33 +/- 9%, respectively. There was a negative correlation, r = -0.65 (p less than 0.001), between the mean basal S.A. and the mean % def. (i.e., the lower the S.A., the higher the % def.). There were students with low basal S.A.'s who showed symptoms of carpal tunnel syndrome. On the basis of these data, 93% of 174 students had deficiencies of 20% and higher which was potentially correctable by oral pyridoxine; these students had B6-deficient diets. On the basis that a normal basal S.A. may be 0.7, and that the maximum S. A. (0.45) for all 174 students is about 65% of 0.7, all 174 students had varying vitamin B6 deficiency, and their diets provided inadequate amounts of this vitamin.

PMID: 7288513 [PubMed - indexed for MEDLINE]

J Neurosurg. 2003 Jun;98(6):1159-64.            Related Articles, Links

Comment in:

•              J Neurosurg. 2003 Jun;98(6):1157-8.

Peripheral nerve surgery and neurosurgeons: results of a national survey of practice patterns and attitudes.

Maniker A, Passannante M.

Department of Neurological Surgery, Neurological Institute of New Jersey, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA. maniker@umdnj.edu

OBJECT: The goal of this study was to determine current practice patterns and attitudes of neurosurgeons toward peripheral nerve surgery. METHODS: A 13-question survey was mailed to all active members of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. Collected responses were entered into a database and were analyzed using statistical software. CONCLUSIONS: Of 3800 surveys mailed there were 1728 responses for a 45% response rate. Analysis of the data revealed that respondents had a greater comfort level with simple peripheral nerve procedures, such as carpal tunnel release, and a lack of comfort with more complex peripheral nerve procedures, such as brachial plexus exploration. The majority of simple cases were treated by the surveyed neurosurgeons, whereas the majority of complex cases were referred to other surgeons, primarily to other neurosurgeons. The type of medical practice (academic, group, or solo) and the location of the practice (major city, small city, suburban setting, or rural area) showed a statistically significant correlation to simple case referral patterns, whereas the length of time since the respondent underwent training did not. Practice type and location, and years since training showed a statistically significant correlation to complex case referral patterns. Only 48.7% of the respondents believed that they had been given sufficient exposure to peripheral nerve surgery during residency training. The overwhelming majority (97.2%) of respondents favored keeping peripheral nerve surgery as part of the neurosurgical curriculum.

PMID: 12816257 [PubMed - indexed for MEDLINE]

Expert Opin Pharmacother. 2003 Jun;4(6):903-9.       Related Articles, Links

Pharmacotherapy of carpal tunnel syndrome.

de Pablo P, Katz JN.

Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, B-3, Boston, MA 02115, USA. pdepablo@hsph.harvard.edu

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome. CTS is a compression neuropathy caused by elevated pressure in the carpal tunnel. CTS has the potential to substantially limit performance of activities of daily living for some individuals. The goal of therapy for CTS is to improve symptoms and reduce signs of the disease, as well as prevent progression and loss of hand function. There are several treatment alternatives to relieve the pressure on the median nerve, both surgical and conservative. The most common measures employed in the initial treatment of CTS are NSAIDs, local and systemic corticosteroids, diuretics and pyridoxine. However, CTS treatment usually includes a combination of pharmacotherapy with other strategies such as splinting and activity modification. Injections of corticosteroids into the carpal tunnel are often employed for cases not responding to conservative treatment. Surgery is superior to conservative therapies for most persistently symptomatic patients. The aim of this paper is to review the pharmacological agents used for relieving the symptoms of CTS.

PMID: 12783587 [PubMed - in process]

Cochrane Database Syst Rev. 2003;(1):CD003219.   Related Articles, Links

Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome.

O'Connor D, Marshall S, Massy-Westropp N.

School of Occupational Therapy, University of South Australia, City East Campus, North Terrace, Adelaide, South Australia, Australia. Denise.OConnor@unisa.edu.au

BACKGROUND: Non-surgical treatment for carpal tunnel syndrome is frequently offered to those with mild to moderate symptoms. The effectiveness and duration of benefit from non-surgical treatment for carpal tunnel syndrome remain unknown. OBJECTIVES: To evaluate the effectiveness of non-surgical treatment (other than steroid injection) for carpal tunnel syndrome versus a placebo or other non-surgical, control interventions in improving clinical outcome. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group specialised register (searched March 2002), MEDLINE (searched January 1966 to February 7 2001), EMBASE (searched January 1980 to March 2002), CINAHL (searched January 1983 to December 2001), AMED (searched 1984 to January 2002), Current Contents (January 1993 to March 2002), PEDro and reference lists of articles. SELECTION CRITERIA: Randomised or quasi-randomised studies in any language of participants with the diagnosis of carpal tunnel syndrome who had not previously undergone surgical release. We considered all non-surgical treatments apart from local steroid injection. The primary outcome measure was improvement in clinical symptoms after at least three months following the end of treatment. DATA COLLECTION AND ANALYSIS: Three reviewers independently selected the trials to be included. Two reviewers independently extracted data. Studies were rated for their overall quality. Relative risks and weighted mean differences with 95% confidence intervals were calculated for the primary and secondary outcomes in each trial. Results of clinically and statistically homogeneous trials were pooled to provide estimates of the efficacy of non-surgical treatments. MAIN RESULTS: Twenty-one trials involving 884 people were included. A hand brace significantly improved symptoms after four weeks (weighted mean difference (WMD) -1.07; 95% confidence interval (CI) -1.29 to -0.85) and function (WMD -0.55; 95% CI -0.82 to -0.28). In an analysis of pooled data from two trials (63 participants) ultrasound treatment for two weeks was not significantly beneficial. However one trial showed significant symptom improvement after seven weeks of ultrasound (WMD -0.99; 95% CI -1.77 to - 0.21) which was maintained at six months (WMD -1.86; 95% CI -2.67 to -1.05). Four trials involving 193 people examined various oral medications (steroids, diuretics, nonsteroidal anti-inflammatory drugs) versus placebo. Compared to placebo, pooled data for two-week oral steroid treatment demonstrated a significant improvement in symptoms (WMD -7.23; 95% CI -10.31 to -4.14). One trial also showed improvement after four weeks (WMD -10.8; 95% CI -15.26 to -6.34). Compared to placebo, diuretics or nonsteroidal anti-inflammatory drugs did not demonstrate significant benefit. In two trials involving 50 people, vitamin B6 did not significantly improve overall symptoms. In one trial involving 51 people yoga significantly reduced pain after eight weeks (WMD -1.40; 95% CI -2.73 to -0.07) compared with wrist splinting. In one trial involving 21 people carpal bone mobilisation significantly improved symptoms after three weeks (WMD -1.43; 95% CI -2.19 to -0.67) compared to no treatment. In one trial involving 50 people with diabetes, steroid and insulin injections significantly improved symptoms over eight weeks compared with steroid and placebo injections. Two trials involving 105 people compared ergonomic keyboards versus control and demonstrated equivocal results for pain and function. Trials of magnet therapy, laser acupuncture, exercise or chiropractic care did not demonstrate symptom benefit when compared to placebo or control. REVIEWER'S CONCLUSIONS: Current evidence shows significant short-term benefit from oral steroids, splinting, ultrasound, yoga and carpal bone mobilisation. Other non-surgical treatments do not produce significant benefit. More trials are needed to compare treatments and ascertain the duration of benefit.

Publication Types:

•              Review

•              Review, Academic

PMID: 12535461 [PubMed - indexed for MEDLINE]

Cochrane Database Syst Rev. 2002;(4):CD003905.   Related Articles, Links

Surgical treatment options for carpal tunnel syndrome.

Scholten RJ, Gerritsen AA, Uitdehaag BM, van Geldere D, de Vet HC, Bouter LM.

Dutch Cochrane Centre, PO Box 22700, Amsterdam, Netherlands, 1100 DE. R.J.Scholten@AMC.UvA.NL

BACKGROUND: Carpal tunnel syndrome is a common disorder, for which several surgical treatment options are available. However, there is no consensus on the most effective method of treatment. OBJECTIVES: To compare the efficacy of the various surgical techniques in relieving symptoms and promoting return to work and/or activities of daily living and to compare the occurrence of side-effects and complications in patients suffering from carpal tunnel syndrome. SEARCH STRATEGY: We conducted computer-aided searches of the Cochrane Controlled Trials Register (Cochrane Library, Issue 1, 2000), MEDLINE(searched January 1966-March 2000) and EMBASE (searched January 1988-February 2000), and tracked references in bibliographies. SELECTION CRITERIA: Randomised controlled trials comparing various surgical techniques for the treatment of carpal tunnel syndrome. DATA COLLECTION AND ANALYSIS: Study selection, assessment of methodological quality and data abstraction were performed by two reviewers independently of each other. MAIN RESULTS: Sixteen studies were included in the review. The methodological quality of the trials was fair to good. However, the application of allocation concealment was mentioned explicitly in only two trials. Many studies failed to present the results in sufficient detail to enable statistical pooling. Pooling was also impeded by the vast variety of outcome measures that were applied in the various studies. None of the existing alternatives to standard open carpal tunnel release seem to offer better relief from symptoms in the short- or long-term. There is conflicting evidence about whether endoscopic carpal tunnel release results in earlier return to work and/or activities of daily living than open carpal tunnel release. REVIEWER'S CONCLUSIONS: There is no strong evidence supporting the need for replacement of standard open carpal tunnel release by existing alternative surgical procedures for the treatment of carpal tunnel syndrome.

Publication Types:

•              Meta-Analysis

•              Review

•              Review, Academic

PMID: 12519618 [PubMed - indexed for MEDLINE]

Cochrane Database Syst Rev. 2002;(4):CD001554.   Related Articles, Links

Update of:

•              Cochrane Database Syst Rev. 2000;(4):CD001554.

Local corticosteroid injection for carpal tunnel syndrome.

Marshall S, Tardif G, Ashworth N.

Medicine, Division of Physical Medicine and Rehabilitation, University of Ottawa, The Rehabilitation Centre, 505 Smyth Road, Ottawa, Ontario, Canada, K1H 8M2. smarshall@ottawahospital.on.ca

BACKGROUND: Carpal tunnel syndrome is a clinical syndrome manifested by signs and symptoms of irritation of the median nerve at the level of the carpal tunnel in the wrist. Local corticosteroid injection for carpal tunnel syndrome has been studied but its effectiveness and duration of benefit of local corticosteroid injection for Carpal tunnel syndrome remain unknown. OBJECTIVES: To evaluate the effectiveness of local steroid injection for carpal tunnel syndrome versus placebo injection or other non-surgical interventions in improving clinical outcome and to determine the length of symptom relief. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group register (searched June 2002), MEDLINE (searched January 1966 to May 2002), EMBASE (searched January 1980 to May 2002)and CINAHL(searched January 1982 to May 2002). SELECTION CRITERIA: We included randomized or quasi-randomized studies of participants with carpal tunnel syndrome treated with local corticosteroid injection. The primary outcome measure was clinical improvement. DATA COLLECTION AND ANALYSIS: Three reviewers independently selected the trials to be included rated for their overall quality. Relative risks and 95% confidence intervals were calculated for each trial and summary relative risks and 95% confidence intervals were also calculated. MAIN RESULTS: We identified nine randomized controlled trials. Four were excluded. One trial demonstrated clinical improvement of carpal tunnel syndrome at one month following local corticosteroid compared to placebo injection (Relative risk 3.83 (95% confidence intervals 1.82 to 8.05)). One trial compared local corticosteroid injection to oral steroid and at three months after treatment there was a significant improvement in the injection group (mean difference -7.00 (95% confidence intervals -11.58 to -2.42)). In one trial the rate of improvement after one month was greater after local than systemic corticosteroid injection (Relative risk 3.17(95% confidence intervals 1.02 to 9.87)). In one trial symptoms did not improve significantly for the injection group at eight weeks after injection compared to treatment with anti-inflammatory medication and splinting (mean difference 0.10 (95% confidence intervals -0.33 to 0.53)). Although local steroid injection did provide benefit compared to Helium-Neon Laser treatment at two weeks after onset of treatment (Relative risk 0.27 (95% CI 0.09 to 0.83), this effect did not hold at six months follow-up (Relative risk 0.76 (95% confidence intervals 0.48 to 1.21). REVIEWER'S CONCLUSIONS: Local corticosteroid injection for carpal tunnel syndrome provides greater clinical improvement in symptoms one month after injection compared to placebo. Symptom relief beyond one month compared to placebo has not been demonstrated. Local corticosteroid injection provides significantly greater clinical improvement compared to oral steroid up to three months after treatment. Local corticosteroid injection does not provide improved clinical outcome compared to either anti-inflammatory treatment and splinting after eight weeks or Helium -Neon laser treatment after six months.

Publication Types:

•              Meta-Analysis

•              Review

•              Review, Academic

PMID: 12519560 [PubMed - indexed for MEDLINE]

Cochrane Database Syst Rev. 2002;(2):CD001552.   Related Articles, Links

Surgical versus non-surgical treatment for carpal tunnel syndrome.

Verdugo RJ, Salinas RS, Castillo J, Cea JG.

Departmento de Ciencias Neurologicas, Universidad de Chile, Santiago, Chile. rverdugo@machi.med.uchile.cl

BACKGROUND: Carpal tunnel syndrome is the clinical condition resulting from the entrapment of the median nerve in the wrist. It has been accepted as the most frequent entrapment neuropathy. The most common symptoms are tingling, numbness, and pain in the hand that may radiate to the forearm or shoulder. There may be weakness and atrophy of the thenar muscles associated with sensory loss in the affected fingers. There is no universally accepted therapy for carpal tunnel syndrome. Surgical treatment is widely preferred to non-surgical or conservative therapies for overtly symptomatic patients, while mild cases are usually not treated. OBJECTIVES: The objective of this review is to compare the efficacy of surgical treatment of carpal tunnel syndrome with non-surgical treatment in improving clinical outcome. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group register for randomised or quasi-randomised trials as well as MEDLINE, EMBASE and LILACS (to July 2001). We checked the bibliographies in relevant papers and contacted the authors to obtain information about other published or unpublished studies. SELECTION CRITERIA: All randomised and quasi-randomised controlled trials comparing any surgical and any non-surgical therapies. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed eligibility of the trials. MAIN RESULTS: Only one randomised controlled trial was found. It included 22 female patients, 11 allocated to surgical section of the anterior carpal ligament and 11 to splinting for one month. The trial was not blinded and it is not clear if the allocation was properly concealed. Data reported allowed an intention-to-treat analysis on two secondary outcomes. The results favour surgery for both of them. There was a significant clinical improvement at one year follow-up in 10 out of 11 patients allocated to surgery and two out of 11 allocated to splinting (relative risk 5.00, 95% confidence interval 1.41, 17.76). Eight out of 11 patients allocated to splinting required surgery during follow-up, compared with apparently no re operation in the surgical group (relative risk 0.06, 95% confidence interval 0.00, 0.91). REVIEWER'S CONCLUSIONS: Surgical treatment of carpal tunnel syndrome seems to be better than splinting. There is a need for randomised controlled trials comparing surgical and non-surgical therapies for carpal tunnel syndrome, particularly in patients with mild symptoms in whom there is greater uncertainty concerning the balance of risks versus benefit of surgical therapy.

Publication Types:

•              Review

•              Review, Academic

PMID: 12076416 [PubMed - indexed for MEDLINE]

J Neurol. 2002 Mar;249(3):272-80.                 Related Articles, Links

Conservative treatment options for carpal tunnel syndrome: a systematic review of randomised controlled trials.

Gerritsen AA, de Krom MC, Struijs MA, Scholten RJ, de Vet HC, Bouter LM.

Institute for Research in Extramural Medicine, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands. aam.gerritsen.emgo@med.vu.nl

Carpal tunnel syndrome (CTS) is a common disorder, for which various conservative treatment options are available. The objective of this study is to determine the efficacy of the various conservative treatment options for relieving the symptoms of CTS. Computer-aided searches of MEDLINE (1/1966 to 3/2000), EMBASE (1/1988 to 2/2000) and the Cochrane Controlled Trials Register (2000, issue 1) were conducted, together with reference checking. Included were randomised controlled trials evaluating the efficacy of conservative treatment options in a study population of CTS patients, with a full report published in English, German, French or Dutch. Two reviewers independently selected the studies. Fourteen randomised controlled trials were included in the review. Assessment of methodological quality and data-extraction was independently performed by two reviewers. A rating system, based on the number of studies and their methodological quality and findings, was used to determine the strength of the available evidence for the efficacy of the treatment. Diuretics, pyridoxine, non-steroidal anti-inflammatory drugs, yoga and laser-acupuncture seem to be ineffective in providing short-term symptom relief (varying levels of evidence) and steroid injections seem to be effective (limited evidence). There is conflicting evidence for the efficacy of ultrasound and oral steroids. For providing long-term relief from symptoms there is limited evidence that ultrasound is effective, and that splinting is less effective than surgery. In conclusion, there is still little known about the efficacy of most conservative treatment options for CTS. To establish stronger evidence more high quality trials are needed.

Publication Types:

•              Meta-Analysis

PMID: 11993525 [PubMed - indexed for MEDLINE]

Altern Ther Health Med. 2002 Mar-Apr;8(2):66-8.      Related Articles, Links

Use of Arnica to relieve pain after carpal-tunnel release surgery.

Jeffrey SL, Belcher HJ.

Department of Plastic Surgery of Queen Victoria Hospital in West Sussex, England.

CONTEXT: Arnica is commonly used by the public as a treatment for bruising and swelling. OBJECTIVE: To assess whether Arnica administration affects recovery from hand surgery. DESIGN: Double-blind, randomized comparison of Arnica administration versus placebo. SETTING: Specialist hand surgery unit at the Queen Victoria NHS Trust. PARTICIPANTS: Thirty-seven patients undergoing bilateral endoscopic carpal-tunnel release between June 1998 and January 2000. INTERVENTION: Homeopathic Arnica tablets and herbal Arnica ointment compared to placebos. MAIN OUTCOME MEASURES: Grip strength, wrist circumference, and perceived pain measured 1 and 2 weeks after surgery. RESULTS: No difference in grip strength or wrist circumference was found between the 2 groups. However, there was a significant reduction in pain experienced after 2 weeks in the Arnica-treated group (P<.03). CONCLUSIONS: The role of homeopathic and herbal agents for recovery after surgery merits further investigation.

Publication Types:

•              Clinical Trial

•              Randomized Controlled Trial

PMID: 11892685 [PubMed - indexed for MEDLINE]

J R Soc Med. 2003 Feb;96(2):60-5.                 Related Articles, Links

Comment in:

•              J R Soc Med. 2003 Apr;96(4):204-5; author reply 206-7.

•              J R Soc Med. 2003 Apr;96(4):204; author reply 206-7.

•              J R Soc Med. 2003 Apr;96(4):205-6; author reply 206-7.

•              J R Soc Med. 2003 Apr;96(4):205; author reply 206-7.

•              J R Soc Med. 2003 Apr;96(4):206; author reply 206-7.

Homeopathic arnica for prevention of pain and bruising: randomized placebo-controlled trial in hand surgery.

Stevinson C, Devaraj VS, Fountain-Barber A, Hawkins S, Ernst E.

Department of Complementary Medicine, University of Exeter, UK.

Homeopathic arnica is widely believed to control bruising, reduce swelling and promote recovery after local trauma; many patients therefore take it perioperatively. To determine whether this treatment has any effect, we conducted a double-blind, placebo-controlled, randomized trial with three parallel arms. 64 adults undergoing elective surgery for carpal tunnel syndrome were randomized to take three tablets daily of homeopathic arnica 30C or 6C or placebo for seven days before surgery and fourteen days after surgery. Primary outcome measures were pain (short form McGill Pain Questionnaire) and bruising (colour separation analysis) at four days after surgery. Secondary outcome measures were swelling (wrist circumference) and use of analgesic medication (patient diary). 62 patients could be included in the intention-to-treat analysis. There were no group differences on the primary outcome measures of pain (P=0.79) and bruising (P=0.45) at day four. Swelling and use of analgesic medication also did not differ between arnica and placebo groups. Adverse events were reported by 2 patients in the arnica 6C group, 3 in the placebo group and 4 in the arnica 30C group. The results of this trial do not suggest that homeopathic arnica has an advantage over placebo in reducing postoperative pain, bruising and swelling in patients undergoing elective hand surgery.

Publication Types:

•              Clinical Trial

•              Randomized Controlled Trial

PMID: 12562974 [PubMed - indexed for MEDLINE]

J Am Board Fam Pract. 2001 Sep-Oct;14(5):335-42. Related Articles, Links

Therapeutic touch in the treatment of carpal tunnel syndrome.

Blankfield RP, Sulzmann C, Fradley LG, Tapolyai AA, Zyzanski SJ.

Department of Family Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.

BACKGROUND: Alternative medical therapies are widely utilized, but there are few objective data to evaluate the effectiveness of these techniques. The purpose of this study was to determine whether one alternative therapy, Therapeutic Touch (TT), can improve objective indices of median nerve function in patients with carpal tunnel syndrome. METHODS: Participants with electrodiagnostically confirmed carpal tunnel syndrome were randomly assigned in single-blind fashion to receive either TT or sham therapeutic touch once weekly for 6 consecutive weeks. The distal latency of the median motor nerve along with visual analog assessments of pain and relaxation were measured before and after each treatment session. RESULTS: Twenty-one participants completed the study. Changes in median motor nerve distal latencies, pain scores, and relaxation scores did not differ between participants in the TT group and participants in the sham treatment group, either immediately after each treatment session or cumulatively. Immediately after each treatment session, however, there were improvements from baseline among all the outcome variables in both groups. CONCLUSIONS: In this small study, TT was no better than placebo in influencing median motor nerve distal latencies, pain scores, and relaxation scores. The changes in the outcome variables from baseline in both groups suggest a possible physiologic basis for the placebo effect.

Publication Types:

•              Clinical Trial

•              Randomized Controlled Trial

PMID: 11572538 [PubMed - indexed for MEDLINE]

J Altern Complement Med. 1999 Feb;5(1):5-26.          Related Articles, Links

Carpal tunnel syndrome: clinical outcome after low-level laser acupuncture, microamps transcutaneous electrical nerve stimulation, and other alternative therapies--an open protocol study.

Branco K, Naeser MA.

Acupuncture Healthcare Services, Westport, Massachusetts, USA.

OBJECTIVE: Outcome for carpal tunnel syndrome (CTS) patients (who previously failed standard medical/surgical treatments) treated primarily with a painless, noninvasive technique utilizing red-beam, low-level laser acupuncture and microamps transcutaneous electrical nerve stimulation (TENS) on the affected hand; secondarily, with other alternative therapies. DESIGN: Open treatment protocol, patients diagnosed with CTS by their physicians. SETTING: Treatments performed by licensed acupuncturist in a private practice office. SUBJECTS: Total of 36 hands (from 22 women, 9 men), ages 24-84 years, median pain duration, 24 months. Fourteen hands failed 1-2 surgical release procedures. INTERVENTION/TREATMENT: Primary treatment: red-beam, 670 nm, continuous wave, 5 mW, diode laser pointer (1-7 J per point), and microamps TENS (< 900 microA) on affected hands. Secondary treatment: infrared low-level laser (904 nm, pulsed, 10 W) and/or needle acupuncture on deeper acupuncture points; Chinese herbal medicine formulas and supplements, on case-by-case basis. Three treatments per week, 4-5 weeks. OUTCOME MEASURES: Pre- and posttreatment Melzack pain scores; profession and employment status recorded. RESULTS: Posttreatment, pain significantly reduced (p < .0001), and 33 of 36 hands (91.6%) no pain, or pain reduced by more than 50%. The 14 hands that failed surgical release, successfully treated. Patients remained employed, if not retired. Follow-up after 1-2 years with cases less than age 60, only 2 of 23 hands (8.3%) pain returned, but successfully re-treated within a few weeks. CONCLUSIONS: Possible mechanisms for effectiveness include increased adenosine triphosphate (ATP) on cellular level, decreased inflammation, temporary increase in serotonin. There are potential cost-savings with this treatment (current estimated cost per case, $12,000; this treatment, $1,000). Safe when applied by licensed acupuncturist trained in laser acupuncture; supplemental home treatments may be performed by patient under supervision of acupuncturist.

Publication Types:

•              Clinical Trial

PMID: 10100028 [PubMed - indexed for MEDLINE]

JAMA. 1998 Nov 11;280(18):1601-3.            Related Articles, Links

Comment in:

•              JAMA. 1999 Jun 9;281(22):2087; discussion 2088-9.

Yoga-based intervention for carpal tunnel syndrome: a randomized trial.

Garfinkel MS, Singhal A, Katz WA, Allan DA, Reshetar R, Schumacher HR Jr.

Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, USA. mariang102@aol.com

CONTEXT: Carpal tunnel syndrome is a common complication of repetitive activities and causes significant morbidity. OBJECTIVE: To determine the effectiveness of a yoga-based regimen for relieving symptoms of carpal tunnel syndrome. DESIGN: Randomized, single-blind, controlled trial. SETTING: A geriatric center and an industrial site in 1994-1995. PATIENTS: Forty-two employed or retired individuals with carpal tunnel syndrome (median age, 52 years; range, 24-77 years). INTERVENTION: Subjects assigned to the yoga group received a yoga-based intervention consisting of 11 yoga postures designed for strengthening, stretching, and balancing each joint in the upper body along with relaxation given twice weekly for 8 weeks. Patients in the control group were offered a wrist splint to supplement their current treatment. MAIN OUTCOME MEASURES: Changes from baseline to 8 weeks in grip strength, pain intensity, sleep disturbance, Phalen sign, and Tinel sign, and in median nerve motor and sensory conduction time. RESULTS: Subjects in the yoga groups had significant improvement in grip strength (increased from 162 to 187 mm Hg; P = .009) and pain reduction (decreased from 5.0 to 2.9 mm; P = .02), but changes in grip strength and pain were not significant for control subjects. The yoga group had significantly more improvement in Phalen sign (12 improved vs 2 in control group; P = .008), but no significant differences were found in sleep disturbance, Tinel sign, and median nerve motor and sensory conduction time. CONCLUSION: In this preliminary study, a yoga-based regimen was more effective than wrist splinting or no treatment in relieving some symptoms and signs of carpal tunnel syndrome.

Publication Types:

•              Clinical Trial

•              Randomized Controlled Trial

PMID: 9820263 [PubMed - indexed for MEDLINE]

JAMA. 1998 Nov 4;280(17):1518-24.            Related Articles, Links

NIH Consensus Conference. Acupuncture.

[No authors listed]

OBJECTIVE: To provide clinicians, patients, and the general public with a responsible assessment of the use and effectiveness of acupuncture to treat a variety of conditions. PARTICIPANTS: A nonfederal, nonadvocate, 12-member panel representing the fields of acupuncture, pain, psychology, psychiatry, physical medicine and rehabilitation, drug abuse, family practice, internal medicine, health policy, epidemiology, statistics, physiology, biophysics, and the representatives of the public. In addition, 25 experts from these same fields presented data to the panel and a conference audience of 1200. Presentations and discussions were divided into 3 phases over 2 1/2 days: (1) presentations by investigators working in areas relevant to the consensus questions during a 2-day public session; (2) questions and statements from conference attendees during open discussion periods that were part of the public session; and (3) closed deliberations by the panel during the remainder of the second day and morning of the third. The conference was organized and supported by the Office of Alternative Medicine and the Office of Medical Applications of Research, National Institutes of Health, Bethesda, Md. EVIDENCE: The literature, produced from January 1970 to October 1997, was searched through MEDLINE, Allied and Alternative Medicine, EMBASE, and MANTIS, as well as through a hand search of 9 journals that were not indexed by the National Library of Medicine. An extensive bibliography of 2302 references was provided to the panel and the conference audience. Expert speakers prepared abstracts of their own conference presentations with relevant citations from the literature. Scientific evidence was given precedence over clinical anecdotal experience. CONSENSUS PROCESS: The panel, answering predefined questions, developed their conclusions based on the scientific evidence presented in the open forum and scientific literature. The panel composed a draft statement, which was read in its entirety and circulated to the experts and the audience for comment. Thereafter, the panel resolved conflicting recommendations and released a revised statement at the end of the conference. The panel finalized the revisions within a few weeks after the conference. The draft statement was made available on the World Wide Web immediately following its release at the conference and was updated with the panel's final revisions within a few weeks of the conference. The statement is available at http://consensus.nih.gov. CONCLUSIONS: Acupuncture as a therapeutic intervention is widely practiced in the United States. Although there have been many studies of its potential usefulness, many of these studies provide equivocal results because of design, sample size, and other factors. The issue is further complicated by inherent difficulties in the use of appropriate controls, such as placebos and sham acupuncture groups. However, promising results have emerged, for example, showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and in postoperative dental pain. There are other situations, such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma, in which acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program. Further research is likely to uncover additional areas where acupuncture interventions will be useful.

Publication Types:

•              Consensus Development Conference

•              Consensus Development Conference, NIH

•              Review

PMID: 9809733 [PubMed - indexed for MEDLINE]

J Hand Ther. 1998 Jul-Sep;11(3):191-9.        Related Articles, Links

Presentation and response of patients with upper extremity repetitive use syndrome to a multidisciplinary rehabilitation program: a retrospective review of 24 cases.

Barthel HR, Miller LS, Deardorff WW, Portenier R.

Cedars-Sinai Medical Center, Los Angeles, California, USA. hrbarthel@earthlink.net

OBJECTIVE: To analyze retrospectively a group of patients presenting to an outpatient hand rehabilitation clinic with complaints related to repetitive tasks of the upper extremity. DESIGN: Retrospective case study reviewing 24 consecutive cases for presenting symptoms and response of patients to a multidisciplinary rehabilitation approach. SETTING: An outpatient hand rehabilitation clinic in a tertiary referral center offering simultaneous medical, psychological, and occupational evaluations. PATIENTS: Twenty-four patients with upper extremity symptoms related to repetitive use, who had all failed various prior therapeutic interventions. Fifty percent of the patients were receiving medical disability compensation because of their symptoms. Sixty-two percent had filed a worker's compensation claim. INTERVENTIONS: Treatment consisted of medical management with pharmacologic interventions, occupational therapy with workplace simulation and job-site evaluations, and psychological treatment with pain management and biofeedback training. Treatments were individualized to meet each patient's needs. OUTCOME MEASURES: Reduction in symptom intensity or frequency, increase in work and performance of activities of daily living, and termination of medical disability with return to work. RESULTS: Most cases (83%) were found to be related to occupational computer keyboard use. Bilateral hand and forearm pain were the major symptoms. A unique physical finding was diffuse tendon tenderness and tightness of the long flexor and extensor muscles of the forearm. Carpal tunnel syndrome was found in only one patient. Twenty-five percent of patients achieved resolution of most symptoms, although on a modified and often reduced activity level; 54% had moderate improvement; and 13% had only minimal or no improvement. Of the patients receiving medical disability compensation, 58% returned to their previous jobs. CONCLUSIONS: Patients with upper extremity symptoms related to repetitive use often have unique physical findings, distinct from those of carpal tunnel syndrome. Resulting work disability is high. Patients who have not responded to conventional interventions within a reasonable time may benefit from a multidisciplinary treatment approach. Most patients improve with this treatment but do not fully recover.

PMID: 9730095 [PubMed - indexed for MEDLINE]

Ergonomics. 1993 Apr;36(4):353-61.             Related Articles, Links

The effects of biofeedback on carpal tunnel syndrome.

Thomas RE, Vaidya SC, Herrick RT, Congleton JJ.

Department of Industrial Engineering, Auburn University, Alabama 36849-5346.

Behaviour modification based on audible electromyographic (EMG) biofeedback signals was used to discourage the awkward hand postures and the exertion of excessive force with the fingers, which are suspected of causing carpal tunnel syndrome (CTS). The null hypothesis was that participation in such a biofeedback programme has no effect on CTS symptoms. Before and during an 8-week study, data were collected from two groups of five female assembly line workers each. The biofeedback group received training and input, while the control group did not. Test results indicated that the null hypothesis could not be rejected.

PMID: 8472685 [PubMed - indexed for MEDLINE]