Effectiveness of Surgical and Postsurgical Interventions for Carpal Tunnel Syndrome-A Systematic Review

Conservative Treatments of Carpal Tunnel Syndrome: A Systematic Review and Network Meta-analysis

OBJECTIVE

To evaluate the comparative efficacy of various conservative treatments for carpal tunnel syndrome (CTS), including manual therapy (MT), local steroid injections, platelet-rich plasma (PRP) injections, extracorporeal shock wave therapy, and low-level laser therapy, through a comprehensive network meta-analysis.

DATA SOURCES

PubMed, Web of Science, Cochrane Library, Embase, SPORTDiscus, and China National Knowledge Infrastructure databases were searched to identify published studies until April 2024.

STUDY SELECTION

Randomized controlled trials comparing the efficacy of conservative CTS treatments in individuals with CTS were included.

DATA EXTRACTION

Data from the included articles were extracted independently by 2 researchers, with any disagreements resolved through consultation with a third author. The extracted data included the first author's name, country/region, publication year, sample size, participants' age, disease severity, symptom duration, intervention parameters, follow-up period, and reported outcomes.

DATA SYNTHESIS

A total of 49 randomized controlled trials involving 11 conservative treatments and 3323 participants were included. The network meta-analysis showed that MT demonstrated the highest efficacy in both short-term and medium-term pain relief with surface under the cumulative ranking curve values of 87.6% and 99.3%, respectively. Dextrose 5% in water and PRP were closely followed in terms of efficacy. Compared to control groups, low-level laser therapy (standardized mean difference=-1.45; 95% CI, -2.16 to -0.74) and extracorporeal shock wave therapy (standardized mean difference=-1.03; 95% CI, -1.86 to -0.20) also showed significant benefits.

CONCLUSIONS

This study provides robust evidence that MT and dextrose 5% in water injections are the most effective conservative treatments for CTS which offer valuable insights for clinical decision-making. Further research is needed to assess the long-term efficacy and cost-effectiveness of these interventions.

Effectiveness of a telerehabilitation tablet app in combination with face-to-face physiotherapy for people with wrist, hand or finger injuries: A pragmatic multicentre clinical trial

OBJECTIVE

To evaluate whether, in patients with trauma and soft tissue injuries of the wrist, hand and/or fingers, an exercise program performed on a touchscreen tablet-based app reduces the consumption of face-to-face resources and improves clinical recovery, compared to a conventional home exercise program prescribed on paper.

DESIGN

Pragmatic, multicentre, parallel, two-group, controlled clinical trial with blinded assessor.

PARTICIPANTS AND SETTING

Eighty-one patients with traumatic bone and/or soft tissue injuries of the hand, wrist and/or fingers recruited in four hospitals of the Andalusian Public Health System.

INTERVENTIONS

The experimental group received a home exercise program using a touchscreen tablet application and the control group received a home exercise program on paper. Both groups received the same treatment of face-to-face physiotherapy.

PRIMARY OUTCOME

Number of physiotherapy sessions. Secondary outcomes were the duration of physiotherapy and clinical variables such as functional ability, grip strength, pain and manual dexterity.

RESULTS

The experimental group required fewer physiotherapy sessions (MD -11,5 sessions; 95% CI -21.4 to -1.4), showed a shorter duration of physiotherapy (MD -3.8 weeks, 95% CI -7 to -1) and had better recovery of grip strength, pain and dexterity compared to the control group.

CONCLUSIONS

In patients with trauma and soft tissue injuries of the wrist, hand and/or fingers, an exercise program performed on a touchscreen tablet-based app in combination with face-to-face physiotherapy reduces the consumption of face-to-face resources and improves clinical recovery, compared to conventional home exercise program prescribed on paper.

Elective hand surgery and concomitant corticosteroid injection: Confirming increased infection risk using A national dataset

Background

Recent studies demonstrate a link between corticosteroid injection and surgical complications when procedures occur shortly after steroid administration. These publications focus on single procedures like carpal tunnel release. This study seeks to demonstrate how surgical site infection risk changes across thirteen common elective hand procedures when steroid injection is performed contemporaneously.

Methods

The Truven MarketScan® database identified patients who had undergone elective hand surgery between 2015 and 2016. Two cohorts were created based on the administration, or absence thereof, of contemporaneous corticosteroid injection. The primary outcome measure was infection within 30 days of surgery as measured by antibiotic prescription or repeat surgical intervention. Multivariate logistic regression was performed to assess the association between concomitant corticosteroid injections and post-operative infections while controlling for demographics and comorbidities.

Results

149,689 patients underwent elective hand surgery. 6104 (4.1 %) received concomitant corticosteroid injection and 14,070 (9.4 %) received post-operative antibiotics or underwent secondary surgical intervention for infection. Treatment for post-operative infection was significantly higher in the corticosteroid group (10.2 % versus 9.3 %; p = 0.02) driven by difference in severe infection requiring surgical intervention (3.7 % versus 3.1 %; p = 0.03). This finding persisted when controlling for demographics and comorbidities with adjusted OR of 1.10 (CI 1.01-1.20) for all infections and 1.16 (CI 1.01-1.33) for severe infections.

Discussion

These results support prior findings that patients undergoing concurrent steroid injections and surgery have increased rates of infectious complications though the absolute risk remains small. Limitations of the database preclude further investigation into the details of each procedure (e.g. ipsilateral vs contralateral injection, peri-operative antibiotics) which may impact infection rates.

Conclusions

Concomitant steroid injection with elective hand surgery may increase the risk of postoperative infection, particularly severe infection. However, that relative increase lies between 1 and 33 percent and should be weighed against the benefit from intraoperative corticosteroid administration.

Long-Term Functional Outcomes and Quality of Life Following Carpal Tunnel Release Surgery

This study investigates the long-term efficacy of carpal tunnel release surgery (CTR) on patient outcomes. We aimed to assess symptom severity, functional limitations, and quality of life in a large cohort (n = 186) at least five years post-surgery via a retrospective cross-sectional design that evaluated participants using the validated Boston Carpal Tunnel Questionnaire (BCTQ) over a phone interview. The BCTQ measures symptom severity, functional limitations, and quality of life specific to carpal tunnel syndrome. Seventy-three percent (73.1%) of patients reported complete resolution of symptoms and functional limitations (BCTQ = 1) with an average follow-up of 11 years. No statistically significant decline in BCTQ scores was observed over time. Univariate analysis revealed a significant association between poorer outcomes and older age at surgery and current unemployment. Carpal tunnel release surgery demonstrates long-term effectiveness in relieving symptoms and improving function in most patients. These findings contribute to the understanding of CTR's impact on patient well-being beyond short-term outcomes.

Local corticosteroid injection versus physical therapy for the treatment of carpal tunnel syndrome: A systematic review and meta-analysis of randomized controlled trials

The comparative effect of commonly used conservative treatments for carpal tunnel syndrome remained controversial. The purpose of this study was to compare the clinical effect of local corticosteroid injection and physical therapy for the treatment of carpal tunnel syndrome. A systematic literature search of PubMed, EMBASE, and Cochrane library was conducted to identify relevant randomized clinical trials published before 21st Mar 2023. Two independent reviewers assayed quality of included studies using the Cochrane collaboration risk of bias tool. Relevant data were extracted and pooled analyses were conducted. Outcome measurements included Boston Carpal Tunnel Syndrome Questionnaire, visual analogue scale and some electrophysiology tests, while the former two were set as the primary outcomes. Subgroup analysis and sensitive analysis were performed and publication bias was evaluated. Heterogeneity among the included studies was examined using the I2 statistic. After selection, 12 studies were identified eligibility for inclusion. Only one study was found to have a high risk of bias. Pooled data of primary outcomes did not show any differences between treatments, and subgroup analysis supported the results. However, patients treated with local corticosteroid injection showed better improvement in distal motor latency (p = 0.002) and compound muscle action potential (p = 0.04). Some studies failed to pass the sensitive analysis, indicating the related analysis might be not so stable. A slight publication bias was observed in subgroup analysis of function scales, among three publication bias test. In conclusion, compared to physical therapy, local corticosteroid injection might have better treatment effects on carpal tunnel syndrome.

Extracorporeal Shock Wave Therapy for the Treatment of Musculoskeletal Pain: A Narrative Review

Extracorporeal shock waves are high-intensity mechanical waves (500-1000 bar) of a microsecond duration with a morphology characterized by a rapid positive phase followed by a negative phase.

BACKGROUND

Extracorporeal shock waves have been used for pain treatment for various sub-acute and chronic musculoskeletal (MSK) problems since 2000. The aim of this article is to update information on the role of extracorporeal shock wave therapy (ESWT) in the treatment of various pathologies that cause MSK pain.

METHODS

Given that in the last two years, articles of interest (including systematic reviews and meta-analyses) have been published on less known indications, such as low back pain, nerve entrapments, osteoarthritis and bone vascular diseases, a literature search was conducted in PubMed, the Cochrane Database, EMBASE, CINAHL and PEDro, with the aim of developing a narrative review of the current literature on this topic. The purposes of the review were to review possible new mechanisms of action, update the level of evidence for known indications and assess possible new indications that have emerged in recent years.

RESULTS

Although extracorporeal shock waves have mechanical effects, their main mechanism of action is biological, through a phenomenon called mechanotransduction. There is solid evidence that supports their use to improve pain in many MSK pathologies, such as different tendinopathies (epicondylar, trochanteric, patellar, Achilles or calcific shoulder), plantar fasciitis, axial pain (myofascial, lumbar or coccygodynia), osteoarthritis and bone lesions (delayed union, osteonecrosis of the femoral head, Kienbock's disease, bone marrow edema syndrome of the hip, pubis osteitis or carpal tunnel syndrome). Of the clinical indications mentioned in this review, five have a level of evidence of 1+, eight have a level of evidence of 1-, one indication has a level of evidence of 2- and two indications have a level of evidence of 3.

CONCLUSIONS

The current literature shows that ESWT is a safe treatment, with hardly any adverse effects reported. Furthermore, it can be used alone or in conjunction with other physical therapies such as eccentric strengthening exercises or static stretching, which can enhance its therapeutic effect.

The effectiveness of biophysical agents in the treatment of carpal tunnel syndrome- an umbrella review

BACKGROUND

Our objective was to summarize, synthesize, and integrate the evidence evaluating the effectiveness of biophysical agents compared to other conservative treatments, for the management of carpal tunnel syndrome (CTS).

METHODS

This was an overview of systematic reviews (SRs). We searched several online databases and obtained SRs relating to managing CTS using biophysical agents. Two independent researchers screened and appraised the quality of the SRs using the A MeaSurement Tool to Assess systematic Reviews-2 appraisal tool. We extracted information related to study characteristics as well as the effectiveness of biophysical agents for CTS, the effect sizes, and between-group significances. We categorized the information based on the type of biophysical agent. We also performed a citation mapping and calculated the corrected covered area index.

RESULTS

We found 17 SRs addressing 12 different biophysical agents. The quality of the SRs was mainly critically low (n = 16) or low (n = 1). The evidence was inconclusive for the effectiveness of Low-level Laser therapy and favorable for the short-term efficacy of non-thermal ultrasound in improving symptom severity, function, pain, global rating of improvement, satisfaction with treatment, and other electrophysiological measures compared to manual therapy or placebo. Evidence was inconclusive for Extracorporeal Shockwave therapy, and favorable for the short-term effectiveness of Shortwave and Microwave Diathermy on pain and hand function. The corrected covered area index was lower than 35% indicating a low overlap of the SRs.

CONCLUSIONS

The findings were based on low-quality primary studies, with an unclear or high risk of bias, small sample sizes, and short follow-ups. Therefore, no recommendations can be made for the long-term effectiveness of any biophysical agents. High-quality evidence is needed to support evidence-based recommendations on the use of biophysical agents in the management of CTS.

PROSPERO REGISTRATION NUMBER

CRD42022319002, registered on 17/04/2022.

Effectiveness of high intensity laser therapy on pain, grip strength and median nerve conductivity in pregnant women with carpal tunnel syndrome: A randomized controlled trial

STUDY DESIGN

Single-blind randomized controlled trial.

INTRODUCTION

High-intensity laser therapy (HILT) was recently introduced to the physiotherapy field as a treatment option for patients with carpal tunnel syndrome (CTS). However, evidence about its effectiveness on pregnant women with CTS is sparse.

PURPOSE OF STUDY

To test the effectiveness of HILT combined with a conventional physical therapy program to reduce pain intensity, sensory and motor nerve distal latency, and increase grip strength in pregnant women with CTS compared with the physical therapy alone.

METHODS

Fifty-four pregnant women with mild to moderate CTS were randomized and further allocated into two groups. The HILT group (n = 27) received both HILT and conventional physical therapy, and the control group (n = 27) received only physical therapy, including nerve and tendon gliding exercises and the use of an orthotic device. Participants received the interventions at the University Hospital (omitted for review) three times per week for 5 weeks. An 11-points numerical pain rating scale, electromyography, and a handheld dynamometer were used for data collection before and after the treatment.

RESULTS

Participants from both groups presented significant improvement in the median nerve motor nerve distal latency (MNDL), sensory nerve distal latency, numerical pain rating scale, and handgrip strength after the intervention. The between-group difference showed more improvements in participants of the HILT group on reducing pain intensity, mean difference (MD) = -3.11 (-4.1 to 2.1), and sensory nerve distal latency, MD = -0.3 (-0.5 to -0.1) compared with the control group.

DISCUSSION

HILT produced greater improvement in outcomes of pregnant women with mild to moderate CTS whichsuggests that adding HILT to traditional CTS physical therapy protocol is beneficial and safe.

CONCLUSIONS

High-intensity laser therapy combined with a standard physical therapy program for CTS in pregnant women is better than the physical therapy program alone to improve pain intensity and median nerve sensory distal latency.

Pathophysiology of Work-Related Neuropathies

Work-related injuries are common. The cost of these injuries is around USD 176 billion to USD 350 billion a year. A significant number of work-related injuries involve nerve damage or dysfunction. Injuries may heal with full recovery of function, but those involving nerve damage may result in significant loss of function or very prolonged recovery. While many factors can predispose a person to suffer nerve damage, in most cases, it is a multifactorial issue that involves both intrinsic and extrinsic factors. This makes preventing work-related injuries hard. To date, no evidence-based guidelines are available to clinicians to evaluate work-related nerve dysfunction. While the symptoms range from poor endurance to cramping to clear loss of motor and sensory functions, not all nerves are equally vulnerable. The common risk factors for nerve damage are a superficial location, a long course, an acute change in trajectory along the course, and coursing through tight spaces. The pathophysiology of acute nerve injury is well known, but that of chronic nerve injury is much less well understood. The two most common mechanisms of nerve injury are stretching and compression. Chronic mild to moderate compression is the most common mechanism of nerve injury and it elicits a characteristic response from Schwann cells, which is different from the one when nerve is acutely injured. It is important to gain a better understanding of work-related nerve dysfunction, both from health and from regulatory standpoints. Currently, management depends upon etiology of nerve damage, recovery is often poor if nerves are badly damaged or treatment is not instituted early. This article reviews the current pathophysiology of chronic nerve injury. Chronic nerve injury animal models have contributed a lot to our understanding but it is still not complete. Better understanding of chronic nerve injury pathology will result in identification of novel and more effective targets for pharmacological interventions.

Carpal tunnel syndrome: updated evidence and new questions

Carpal tunnel syndrome is the most common entrapment neuropathy, affecting quality of life for many people. Although it is a well recognised condition, new insights into epidemiology, diagnosis, and treatment have emerged in the past 6 years. The availability of disease-modifying treatments for rare systemic disorders associated with carpal tunnel syndrome (eg, amyloidosis) should alert clinicians to these diagnostic possibilities. Besides clinical evaluation and electrophysiology, the role of ultrasonography as a diagnostic tool has been confirmed and new ultrasound techniques have been applied, the clinical use and feasibility of which require further investigation. Surgical and non-surgical interventions are beneficial for the treatment of carpal tunnel syndrome and several treatment options are now available, giving clinicians the possibility to choose the best approach for every patient. New diagnostic and therapeutic techniques require further validation.

Density mapping of nerve endings in the skin of the palm and flexor retinaculum of the hand. Application to open carpal tunnel release

In order to re-evaluate the safest area to incise skin and the flexor retinaculum (FR) when performing a carpal tunnel release (CTR), we carried out a mapping study of the nerve endings in the skin and FR on cadaver specimens, which, unlike previous studies for the first time, includes histomorphometry and image digital analysis. After dividing the skin and FR into 20 and 12 sections, respectively, we carried out a histomorphological analysis of nerve endings. The analysis was performed by two neutral observers on 4-μm histological sections stained with hematoxylin-eosin (H-E), and Klüver-Barrera with picrosirius red (KB + PR) methods. A semi-automatic image digital analysis was also used to estimate the percentage of area occupied per nerve. We observed a lower quantity of nerve endings in the skin of the palm of the hand in line with the ulnar aspect of the 4th finger. The ulnar aspect of the FR was the most densely innervated. However, there are no statistically significant differences between sections in the percentage of area occupied per nerve both in the skin and in the FR. We concluded that there is not a safe area to incise when performing carpal tunnel surgery, but taking into account the quantity of nerve endings present in skin and FR, we recommend an incision on the axis of the ulnar aspect of 4th finger when incising skin and on the middle third of the FR for CTR.

Comparison of Two Manual Therapy Programs, including Tendon Gliding Exercises as a Common Adjunct, While Managing the Participants with Chronic Carpal Tunnel Syndrome

Background

Carpal tunnel syndrome (CTS) is the symptomatic compression neuropathy of the median nerve at the wrist level that may become a reason for upper limb disability, in the women and men population.

Objective

This study aimed to compare the efficacy of the neurodynamic technique (NT) and carpal bone mobilization technique (CBMT) incorporated with tendon gliding exercises (TGE) as an effect-enhancing adjunct while managing the participants with chronic CTS.

Methods

The study followed a two-arm parallel-group randomized comparative design. Thirty participants (aged 30–59 years) with chronic CTS were recruited randomly to both the NT and CBMT groups. In addition to the TGE (a common adjunct), NT and CBMT were performed in the NT and CBMT groups, respectively, for three weeks. The primary outcome measures including pain intensity, functional status, grip strength, and motor nerve conduction study were assessed using a visual analogue scale (VAS), Boston Carpal Tunnel Questionnaire (BCTQ), hand-held dynamometer, and electromyograph, respectively, at baseline, 3 weeks postintervention, and follow-up at one week post end of the intervention. Paired and unpaired t-test were used to calculate the differences in intervention effects within and between the groups with keeping the level of significance α at 0.05.

Results

The data analysis revealed a significant (95% CI, p < 0.05) difference for all outcomes within each group compared across different time intervals. Similarly, a significant difference was found for all outcomes except pain and grip strength compared between groups at 3 weeks postintervention and follow-up at one week post end of the intervention.

Conclusions

The NT revealed more effectiveness than the CBMT when incorporated with TGE to improve nerve conduction velocity and functional status of the hand. However, both NT and CBMT were equally effective in improving pain and grip strength while managing the participants with chronic CTS. In addition, the TGE contributed as a beneficial, effect-enhancing adjunct to the NT and CBMT differently. Significance. The study will guide the physiotherapist in applying either of the combination techniques suitable for achieving treatment objectives while managing the participants with chronic CTS.

Extracorporeal Shock Wave Therapy Provides Limited Therapeutic Effects on Carpal Tunnel Syndrome: A Systematic Review and Meta-Analysis

Night wrist splinting has been a conservative treatment for carpal tunnel syndrome. The addition of extracorporeal shock wave therapy provides an alternative treatment. However, strong evidence on the clinical effectiveness of extracorporeal shock wave therapy for carpal tunnel syndrome is still lacking. This study aimed to investigate the effectiveness and safety of extracorporeal shock wave therapy compared with treatments of night wrist splints alone for patients with carpal tunnel syndrome. In this systematic review and meta-analysis, no limitation criteria were used for study selection. All available articles that compare the effectiveness between extracorporeal shock wave therapy combined with night wrist splint and night wrist splint alone for treating carpal tunnel syndrome published up to 20 January 2022 were identified from the databases of PubMed, Embase, and Cochrane Central Register of Controlled Trials Central. The primary outcomes were a standard mean difference with a 95% confidence interval on the improvement of symptom severity and functional impairment between the two groups. In an attempt to analyze trends over time in studies that report repeated measurements, an all time-points meta-analysis (ATM) was undertaken. Seven randomized controlled trials with a total of 376 participants were included in this study. Significant improvements in functional impairment and symptom remission were only observed in the extracorporeal shock wave group at four weeks post-treatment. Extracorporeal shock wave therapy did not demonstrate superior efficacy compared to treatment with night wrist splint alone at 8-10 and 12-14 weeks post-treatment, or through the ATM approach. In conclusion, the therapeutic effect of extracorporeal shock wave therapy is transient and mostly nonsignificant compared with using night wrist splint alone. No serious side effects were reported in all included studies. Other conservative treatments to ameliorate carpal tunnel syndrome symptoms are warranted.

The long-term analgesic effectiveness of platelet-rich plasma injection for carpal tunnel syndrome: a cross-sectional cohort study

OBJECTIVE

Interest in perineural platelet-rich-plasma (PRP) injections for the treatment of carpal tunnel syndrome (CTS) has increased in recent years. However, evidence supporting the long-term effectiveness of PRP is lacking. Therefore, the aim of our cross-sectional cohort study was to investigate the long-term results of PRP injections for CTS.

METHODS

Eighty-one patients diagnosed with CTS of any grade who received a single PRP injection at least 2 years prior were enrolled. Through structured telephone interviews, all patients were asked of their post-injection outcomes compared to their pre-injection condition. Symptom relief ≥50%, compared to the pre-injection condition, was considered an effective outcome. Binary logistic regression was applied to analyze each baseline variable as a regressor for determining the prognostic outcome factors.

RESULTS

In total, 70% of patients reported positive outcomes ≥2 years post-injection. Shorter duration of symptoms before treatment (odds ratio: 0.991; 95% confidence interval [CI] 0.983-0.999; p = 0.023) and lower electrodiagnostic severity of CTS were the main prognostic factors for an effective outcome (mild grade vs. severe grade, odds ratio: 17.652; 95% CI 1.43-221.1; p = 0.025). Although there was a trend toward positive outcomes at longer follow-up durations (2-3 years vs. 3-4 years vs. 4-5 years), the difference was not statistically significant.

CONCLUSION

A single perineural PRP injection has a long-term analgesic effect on CTS, especially in mild-to-moderate cases.

Time to Stop Routinely Prescribing Opiates after Carpal Tunnel Release

BACKGROUND

North American surgeons continue to routinely order narcotic medication for postoperative pain relief after carpal tunnel surgery. For some patients, this instigates persistent use. This double-blind, multicenter trial investigated whether over-the-counter medications were inferior to opioid pain control after carpal tunnel release.

METHODS

Patients undergoing carpal tunnel release in five centers in Canada and the United States (n = 347) were randomly assigned to postoperative pain control with (opioid) hydrocodone/acetaminophen 5/325 mg versus over-the-counter ibuprofen/acetaminophen 600/325 mg. The two primary outcome measures were the Numeric Pain Rating Scale (0 to 10) and the six-item Patient-Reported Outcome Measurement Information System Pain Interference T-score. Secondary outcome measures were total medication used and overall satisfaction with pain medication management.

RESULTS

The authors found no significant differences between opioid and over-the-counter patients in the Numeric Pain Rating Scale scores, Pain Interference T-scores, number of doses of medication, or patient satisfaction. The highest Numeric Pain Rating Scale group difference was the night of surgery, when opiate patients had 0.9/10 more pain than over-the-counter patients. The highest group difference in Pain Interference T-scores (2.1) was on the day of surgery, when the opiate patients had more pain interference than the over-the-counter group. Patient nationality or sex did not generate significant pain score differences.

CONCLUSIONS

Pain management is not inferior for patients managed with over-the-counter acetaminophen/ibuprofen versus opioids. This study provides high-quality evidence that U.S. and Canadian surgeons should stop the routine prescription of narcotics after carpal tunnel surgery for patients who are not taking pain medicines daily before surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Quality analysis of prior systematic reviews of carpal tunnel syndrome: an overview of the literature

BACKGROUND

Carpal tunnel syndrome (CTS) is a common condition greatly affects patients' quality of life and ability to work. Systematic reviews provide useful information for treatment and health decisions.

OBJECTIVE

This study aimed to assess the methodological quality of previously published systematic reviews on the treatment of CTS.

DESIGN AND SETTING

Overview of systematic reviews conducted at the Brazilian public higher education institution, São Paulo, Brazil.

METHODS

We searched the MEDLINE and Cochrane Library database for systematic reviews investigating the treatment of CTS in adults. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and measurement tool to assess systematic reviews (AMSTAR) were applied by two independent examiners.

RESULTS

Fifty-five studies were included. Considering the stratification within the AMSTAR measurement tool, we found that more than 76% of the analyzed studies were "low" or "very low". PRISMA scores were higher when meta-analysis was present (15.61 versus 10.40; P = 0.008), while AMSTAR scores were higher when studies performed meta-analysis (8.43 versus 5.59; P = 0.009) or when they included randomized controlled trials (7.95 versus 6.06; P = 0.043). The intra-observer correlation demonstrated perfect agreement (> 0.8), a Spearman's correlation coefficient of 0.829, and an ICC of0.857. The inter-observer correlation indicated that AMSTAR was more reliable than PRISMA.

CONCLUSION

Overall, systematic reviews of the treatment of CTS are of poor quality. Reviews with better-quality conducted meta-analysis and included randomized controlled trials. AMSTAR is a better tool than PRISMA because it has a better performance and should be recommended in future studies.

REGISTRATION NUMBER IN PROSPERO

CRD42020172328 (https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42020172328).

Effects of shock wave therapy in patients with carpal tunnel syndrome: a systematic review and meta-analysis

PURPOSE

To determine whether shock wave therapy could improve symptoms and hand function in patients with carpal tunnel syndrome.

MATERIALS AND METHODS

Medline, Embase, Physiotherapy Evidence Database, the Cochrane Central Register of Controlled Trials, OpenGrey, CNKI, VIP, Wang Fang databases, and China Biological Medicine were searched, from inception to December 2019.

RESULTS

Ten trials involving 433 patients (501 wrists) were included in this systematic review. The shock wave therapy was observed to have a significant effect on pain relief (MD: -0.60, 95% CI: -1.16 to -0.05, p = 0.03), syndrome alleviation (MD: -2.26, 95% CI: -3.24 to -1.27, p < 0.00001) and functional recovery (MD: -1.25 95% CI: -2.08 to -0.43, p = 0.003) among the carpal tunnel syndrome patients. As revealed by the subgroup analysis, radial shock wave therapy made a significant difference in pain relief, syndrome alleviation, and functional recovery (p < 0.05). Focused shock wave had no significant effect on pain relief, syndrome alleviation, and functional recovery (p > 0.05).

CONCLUSION

Shock wave therapy could be conductive to improve syndrome and hand function for carpal tunnel syndrome patients.Implications for rehabilitationShock wave therapy is beneficial for alleviating syndrome and improving hand function of carpal tunnel syndrome patients.Radial shock wave therapy seems superior to focused shock wave therapy on syndrome alleviation and functional recovery of hand in carpal tunnel syndrome patients.

Basal joint arthroplasty and carpal tunnel release comparing a single versus double incision: a prospective randomized study

PURPOSE

Basal thumb joint osteoarthritis frequently coexists with carpal tunnel syndrome. The two conditions have traditionally been treated surgically through separate incisions. We sought to determine whether carpal tunnel release using a single incision during basal joint arthroplasty is as effective as a two-incision approach in patients with concomitant carpal tunnel syndrome and basal thumb joint osteoarthritis.

METHODS

For this purpose, 40 patients were randomly allocated to either a single-incision or double-incision approach, all of whom completed the full follow-up period. The Boston Carpal Tunnel Questionnaire, QuickDASH, and a 10-point visual analog scale pain-severity rating were obtained from patients 3, 6 and 12 months post-operatively.

RESULTS

The two treatment groups experienced comparable, progressive improvement in all symptom-, function-, and pain-related outcomes, with mean surgery time significantly shorter with the single-incision approach, and four versus zero patients in the double-incision group developing pillar pain (p = 0.035).

CONCLUSIONS

Concomitant basal thumb joint osteoarthritis and carpal tunnel syndrome might be effectively performed through a single-incision approach, potentially avoiding any morbidity classically associated with a second incision.

LEVEL OF EVIDENCE

Level II/Therapeutic Study.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04391751, 04/29/2020, retrospectively registered.

Does diabetes mellitus change the carpal tunnel release outcomes? Evidence from a systematic review and meta-analysis

STUDY DESIGN

A systematic review and meta-analysis.

INTRODUCTION

Carpal tunnel syndrome (CTS) is one of the most common upper extremity conditions which mostly affect women. Management of patients suffering from both CTS and diabetes mellitus (DM) is challenging, and it was suggested that DM might affect the diagnosis as well as the outcome of surgical treatment.

PURPOSE OF THE STUDY

This meta-analysis was aimed to compare the response with CTS surgical treatment in diabetic and nondiabetic patients.

METHODS

Electronic databases were searched to identify eligible studies comparing the symptomatic, functional, and neurophysiological outcomes between diabetic and nondiabetic patients with CTS. Pooled MDs with 95% CIs were applied to assess the level of outcome improvements.

RESULTS

Ten articles with 2869 subjects were included. The sensory conduction velocities in the wrist-palm and wrist-middle finger segments showed a significantly better improvement in nondiabetic compared with diabetic patients (MD = -4.31, 95% CI = -5.89 to -2.74, P < .001 and MD = -2.74, 95% CI = -5.32 to -0.16, P = .037, respectively). However, no significant differences were found for the improvement of symptoms severity and functional status based on the Boston Carpal Tunnel Questionnaire and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire as well as motor conduction velocities and distal motor latencies.

CONCLUSION

Metaresults revealed no significant difference in improvements of all various outcomes except sensory conduction velocities after CTS surgery between diabetic and nondiabetic patients. A better diabetic neuropathy care is recommended to achieve better sensory recovery after CTS surgery in diabetic patients.

Efficacy of platelet-rich plasma as an adjuvant to surgical carpal ligament release: a prospective, randomized controlled clinical trial

The purpose of this study is to evaluate the efficiency of local platelet-rich plasma (PRP) injection as an adjuvant treatment after carpal ligament release. We conducted a prospective randomized, triple-blinded, controlled trial. Fifty participants with mild to extreme carpal tunnel syndrome (CTS) were randomly assigned either to the PRP (n = 25) or the platelet-poor plasma (PPP, n = 25) group. After performing open surgical release of the carpal ligament, the inside of the carpal tunnel was irrigated with 3 mL of PRP or PPP according to each participant’s group allocation. The primary outcome was hand grip strength (HGS). Secondary outcomes were the time taken off work after surgery (in days) and scores on the Wong–Baker Faces Scale, Boston Carpal Tunnel Questionnaire, and Southampton Wound Assessment Scale. We evaluated patients before treatment and at 6-weeks. As expected, the pain levels, symptom severity, and functional status improved in all the patients after surgery. However, intragroup analysis revealed that only the participants in the PRP group had regained their pre-operative HGS levels at 6-weeks follow-up. These findings indicate that PRP is an effective adjuvant treatment in patients with mild to severe CTS who require surgery.

Recent Advances in the Understanding and Management of Carpal Tunnel Syndrome: a Comprehensive Review

PURPOSE OF REVIEW

Carpal tunnel syndrome (CTS) is an entrapment neuropathy that involves the compression of the median nerve at the wrist and is considered the most common of all focal entrapment mononeuropathies. CTS makes up 90% of all entrapment neuropathies diagnosed in the USA and affects millions of Americans.

RECENT FINDINGS

Age and gender likely play a role in the development of CTS, but additional studies may further elucidate these associations. Of known associated risk factors, diabetes mellitus seems to have the greatest association with CTS. One of the most commonly reported symptoms in CTS is a "pins-and-needles" sensation in the first three fingers and nocturnal burning pain that is relieved with activity upon waking. Treatment for CTS is variable depending on the severity of symptoms. Conservative management of CTS is usually considered first-line therapy. In cases of severe sensory or motor deficit, injection therapy or ultimately surgery may then be considered. Still CTS is often difficult to treat and may be reoccurring. Novel treatment modalities such as laser and shockwave therapy have demonstrated variable efficacy though further studies are needed to assess for safety and effect. Given the unknown and potentially complex etiology of CTS, further studies are needed to explore combinations of diagnostic and therapeutic modalities.

Extracorporeal Shockwave Therapy in Pillar Pain after Carpal Tunnel Release: A Prospective Randomized Controlled Trial

Background

The aim of this study was to evaluate the effect of extracorporeal shockwave therapy (ESWT) on pillar pain after carpal tunnel release.

Materials and Methods

In this prospective randomized controlled trial, forty patients with pillar pain for at least 1 month after carpal tunnel release surgery were randomly assigned in two groups. ESWT group received four sessions of ESWT at weekly intervals, and patients in the control group received sham ESWT treatment at the same intervals, involved sound but no energy. At baseline, 1^st month, and 3^rd month, hand function (using Brief-Michigan Hand Outcome Questionnaire) and pain score were assessed and compared between groups.

Results

At baseline, pain score and hand function score were similar in both groups. After 1^st month, pain score in ESWT and control groups was 3.7 versus 4.7, respectively (P = 0.066), and hand function score was 60.7 versus 52.2, respectively (P = 0.032). After 3 months, pain score in ESWT group was significantly lower than the control group (1.6 versus 3.6, respectively, P < 0.0001), hand function score in ESWT group was significantly better than the control group (75.4 vs. 63.7, respectively, P < 0.0001). Trend of decrease in pain score between groups was significantly different, but trend of increase in hand function score was not significantly different.

Conclusion

After ESWT, hand function and pain score in patients with pillar pain improved faster compared to control patients. Hence, ESWT can be used as a safe and effective noninvasive technique in patients with pillar pain after carpal tunnel release.