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QUESTION: In patients with carpal tunnel syndrome (CTS), what is the effectiveness of non-surgical treatment (other than steroid injection) compared with no treatment, placebo, or another non-surgical treament for improving clinical outcome?
Studies were identified by searching 7 databases and reviewing the reference lists of identified trials.
Published and unpublished studies were selected if they were randomised controlled trials comparing a non-surgical treatment (other than steroid injections) with no treatment, placebo, or another non-surgical treatment in patients with CTS. Studies of patients with previous surgery for CTS were excluded.
Data were extracted by 2 independent reviewers on patients, interventions, outcome measures, and results. Study quality was assessed using a descriptive approach according to the Cochrane Reviewers’ Handbook. Main outcome was improvement in clinical symptoms (eg, pain and paraesthesiae) ≥3 months after the end of treatment.
21 trials met the selection criteria. Interventions evaluated were splinting (3 trials); ultrasound (3 trials); ergonomic keyboards (2 trials); oral medications or vitamins (6 trials); and 1 trial each of exercise, yoga, mobilisation, magnet therapy, chiropractic care, laser acupuncture, and insulin injection. Duration of treatment ranged from 45 minutes to 6 months. 10 of the trials had a high bias rating; 8 had a moderate rating. Only 3 trials assessed the main outcome measure. Improvement in ≥1 outcome measure occurred with 9 of the 12 interventions (see table on website). No difference was seen with magnet therapy, exercise, or laser acupuncture, and chiropractic care led to an increase in physical distress (see table on website).
In patients with carpal tunnel syndrome, most non-surgical treatments do not seem to improve short term clinical outcome.
In applying the results of the review by O’Connor et al to clinicians, the trial diagnostic selection criteria are important. 17 of the 21 trials were rated highly because they included both electrodiagnostic findings and symptoms of CTS.
Regarding treatment efficacy, the reviewers took the patients’ perspective by measuring clinical symptom improvement ≥3 months after the end of treatment as the primary outcome measure. Unfortunately, only 3 of the 21 studies had data on this outcome. The results of the other studies were based only on such secondary outcomes as electrodiagnostic test results and need for surgery.
The review found moderate evidence for short term benefit from oral steroids; limited evidence for short term benefit from splinting, ultrasound, yoga, and carpal bone mobilisation; and no good evidence for other non-surgical treatments. Of these, oral steroids may be the cheapest and simplest to implement, but side effects may be a concern. The other beneficial treatments may be more expensive and resource intensive, but also safer.
2 previous Cochrane reviews that evaluated steroid injections 1 and surgery 2 for CTS put the results of O’Connor et al in perspective. Marshall et al showed that steroid injections were superior to placebo 1 month 1 after injection, but symptom relief beyond 1 month has not been shown. Steroid injections were superior to oral steroids up to 3 months after treatment, although other studies have shown they were no better than anti-inflammatory treatment and splinting at 8 weeks or laser treatment at 6 months.1 Surgery was superior to splinting at 1 year in 1 small randomised trial.2
The table is available as a downloadable PDF (printer friendly file).
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Files in this Data Supplement:
- [View PDF] - Main results Nonsurgical interventions for carpal tunnel syndrome at 2 weeks to 6 months of follow up
Source of funding: no external funding.
For correspondence: Ms D O’Connor, Monash University and Monash Medical Centre, Clayton, Victoria, Australia.