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Chaudhary R, Khanna J, Bansal S, Bansal N. Current Insights into Carpal Tunnel Syndrome: Clinical Strategies for Prevention and Treatment. Curr Drug Targets 2024; 25:221-240. [PMID: 38385490 DOI: 10.2174/0113894501280331240213063333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/01/2024] [Accepted: 01/12/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Carpal tunnel syndrome (CTS) is a condition that is caused by medial nerve compression, resulting in symptoms such as numbness, tightness, or weakness in the hand. OBJECTIVES The aim of the study was to find out the genetic modulation, mechanism, available treatment, and recommendation for carpal tunnel syndrome at its specific stage. METHODS Almost 200 papers were searched for this review article, and 145 articles were selected. The literature was collected from different sources like Google scholar, PubMed, a directory of open-access journals, and science.gov by using keywords, such as treatment, risk factors, recommendation, and clinical features of carpal tunnel syndrome. RESULTS The most efficient non-surgical treatment is methylprednisolone acetate, which reduces inflammation by acting on the glucocorticoid receptor in conjunction with immunofilling. It has also been used successfully as a second-line drug for the treatment of patients with mild or moderate conditions in order to provide relief. New non-pharmacological options include laser therapy in acupuncture, transcutaneous electric nerve stimulation (TENS), and sham therapy. Modern treatments like TENS, laser therapy, splints, and injections of methylprednisolone acetate have been demonstrated to be helpful in sporadic situations. For patients with mild and moderate problems, more research should be conducted that includes the combination of these surgical and non-surgical treatments. CONCLUSION We propose a multifunctional panel construct and define standard data items for future research into carpal tunnel syndrome. A discussion on idiopathic carpal tunnel syndrome, risk factors, combination of therapies, using guidelines-based recommendations and treatment should be initiated.
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Affiliation(s)
- Rishabh Chaudhary
- Department of Pharmacology, M. M. College of Pharmacy, Maharishi Markandeshwar (Deemed to be University), Mullana, Ambala, Haryana-133207, India
| | - Janvi Khanna
- Department of Pharmacology, M. M. College of Pharmacy, Maharishi Markandeshwar (Deemed to be University), Mullana, Ambala, Haryana-133207, India
| | - Seema Bansal
- Department of Pharmacology, M. M. College of Pharmacy, Maharishi Markandeshwar (Deemed to be University), Mullana, Ambala, Haryana-133207, India
| | - Nitin Bansal
- Department of Pharmacy, Chaudhary Bansilal University, Bhiwani, India
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Abdolrazaghi HA, Khansari M, Mirshahi M, Ahmadi Pishkuhi M. Effectiveness of Tendon and Nerve Gliding Exercises in the Treatment of Patients With Mild Idiopathic Carpal Tunnel Syndrome: A Randomized Controlled Trial. Hand (N Y) 2023; 18:222-229. [PMID: 33855879 PMCID: PMC10035085 DOI: 10.1177/15589447211006857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is limited evidence regarding the efficacy of different treatment options in patients with carpal tunnel syndrome (CTS). This study aimed at assessing the effectiveness of nerve and tendon gliding exercises in the treatment of patients with mild CTS. METHODS The current prospective, randomized trial with pretest-posttest design was conducted on 80 patients with mild CTS randomly assigned to 2 groups. The treatment group was instructed to perform gliding exercises in addition to the wrist splint use. The control group only used the wrist splint. All the patients were instructed to use the splint at night and during the day if required. Patients were evaluated in terms of clinical parameters (ie, grip and pinch strength). The severity of symptoms and functional status was also determined using the Boston Carpal Tunnel Syndrome Questionnaire. The subjects were followed up for 6 weeks. RESULTS There were no significant differences in all parameters between groups. The pretest-posttest analysis showed a statistically significant improvement in subjective and objective parameters in the treatment group. However, in the control group, only a significant improvement was observed in grip strength. Wrist splint use led to a significant change in the severity of symptoms only over the second week. CONCLUSIONS Both gliding exercise and wrist splint groups showed some improvement in the severity of symptoms and functional status scores. However, the gliding exercises did not offer additional benefit compared with wrist splint alone.
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Affiliation(s)
- Hossein Ali Abdolrazaghi
- Department of Hand and Reconstructive Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahmoud Khansari
- Department of Hand and Reconstructive Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Mirshahi
- Department of Hand and Reconstructive Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahin Ahmadi Pishkuhi
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
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Pathophysiology, Diagnosis, Treatment, and Genetics of Carpal Tunnel Syndrome: A Review. Cell Mol Neurobiol 2022:10.1007/s10571-022-01297-2. [PMID: 36217059 DOI: 10.1007/s10571-022-01297-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 10/05/2022] [Indexed: 11/03/2022]
Abstract
Carpal tunnel syndrome (CTS) is a common peripheral canalicular nerve entrapment syndrome in the upper extremities. The compression of or injury to the median nerve at the wrist as it passes through a space-limited osteofibrous carpal canal can cause CTS, resulting in hand pain and impaired function. The present paper reviews the literature on the prevalence, pathology, diagnosis, treatment, and risk factors of CTS in conjunction with the role of genetic factors in CTS etiology. CTS diagnosis is primarily linked with clinical symptoms; still, it is simplified by sophisticated approaches such as magnetic resonance imaging and ultrasonography. CTS symptoms can be ameliorated through conservative and surgical strategies. The exact CTS pathophysiology needs clarification. Genetic predispositions to CTS are augmented by various variants within genes; however, CTS etiology could include risk factors such as wrist movements, injury, and specific conditions (e.g., age, body mass index, sex, and cardiovascular conditions). The high prevalence of CTS diminishes the quality of life of its sufferers and imposes costs on health systems, hence the significance of research and clinical trials to elucidate CTS pathogenesis and develop novel therapeutic targets.
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Sensory Nerve Conduction Velocity Predicts Improvement of Hand Function with Nerve Gliding Exercise Following Carpal Tunnel Release Surgery. J Clin Med 2021; 10:jcm10184121. [PMID: 34575232 PMCID: PMC8470096 DOI: 10.3390/jcm10184121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/04/2021] [Accepted: 09/10/2021] [Indexed: 12/31/2022] Open
Abstract
This study aims to investigate the effects of nerve gliding exercise following carpal tunnel release surgery (NGE-CTRS) and the probing factors affecting the effect of NGE-CTRS on hand function. A total of 86 patients after CTRS participated. Grip strength (grip-s), pinch strength (pinch-s), Semmes-Weinstein monofilament test (SWMT), two-point discrimination (2PD), numbness, pain, and Phalen test (Phalen) were measured and compared between pre- and post-NGE-CTRS. The results showed that the combination of surgery and NGE significantly improved the postoperative grip-s, pinch-s, SWMT, 2PD, numbness, and Phalen; however, no improvement was observed in pain. Background factors that influenced the improved grip-s and pinch-s included gender and preoperative sensory nerve conduction velocity (SCV). Additionally, numbness and Phalen were not affected by age, gender, fault side, bilateral, trigger finger, dialysis, thenar eminence atrophy, motor nerve conduction velocity, SCV, the start of treatment, and occupational therapy intervention. In conclusion, the combination of surgical procedures and NGE showed a high improvement. SCV and time-to-start treatment of intervention for carpal tunnel syndrome may be useful in predicting the function after the intervention.
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Mezian K, Jačisko J, Kaiser R, Machač S, Steyerová P, Sobotová K, Angerová Y, Naňka O. Ulnar Neuropathy at the Elbow: From Ultrasound Scanning to Treatment. Front Neurol 2021; 12:661441. [PMID: 34054704 PMCID: PMC8160369 DOI: 10.3389/fneur.2021.661441] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/23/2021] [Indexed: 01/01/2023] Open
Abstract
Ulnar neuropathy at the elbow (UNE) is commonly encountered in clinical practice. It results from either static or dynamic compression of the ulnar nerve. While the retroepicondylar groove and its surrounding structures are quite superficial, the use of ultrasound (US) imaging is associated with the following advantages: (1) an excellent spatial resolution allows a detailed morphological assessment of the ulnar nerve and adjacent structures, (2) dynamic imaging represents the gold standard for assessing the ulnar nerve stability in the retroepicondylar groove during flexion/extension, and (3) US guidance bears the capability of increasing the accuracy and safety of injections. This review aims to illustrate the ulnar nerve's detailed anatomy at the elbow using cadaveric images to understand better both static and dynamic imaging of the ulnar nerve around the elbow. Pathologies covering ulnar nerve instability, idiopathic cubital tunnel syndrome, space-occupying lesions (e.g., ganglion, heterotopic ossification, aberrant veins, and anconeus epitrochlearis muscle) are presented. Additionally, the authors also exemplify the scientific evidence from the literature supporting the proposition that US guidance is beneficial in injection therapy of UNE. The non-surgical management description covers activity modifications, splinting, neuromobilization/gliding exercise, and physical agents. In the operative treatment description, an emphasis is put on two commonly used approaches-in situ decompression and anterior transpositions.
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Affiliation(s)
- Kamal Mezian
- Department of Rehabilitation Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Jakub Jačisko
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Radek Kaiser
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital Prague, Prague, Czechia
| | - Stanislav Machač
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Petra Steyerová
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Karolína Sobotová
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Yvona Angerová
- Department of Rehabilitation Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Ondřej Naňka
- Institute of Anatomy, First Faculty of Medicine, Charles University, Prague, Czechia
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Abstract
Carpal tunnel syndrome (CTS) is a common medical condition that remains one of the most frequently reported forms of median nerve compression. CTS occurs when the median nerve is squeezed or compressed as it travels through the wrist. The syndrome is characterized by pain in the hand, numbness, and tingling in the distribution of the median nerve. Risk factors for CTS include obesity, monotonous wrist activity, pregnancy, genetic heredity, and rheumatoid inflammation. The diagnosis of CTS is conducted through medical assessments and electrophysiological testing, although idiopathic CTS is the most typical method of diagnosis for patients suffering from these symptoms. The pathophysiology of CTS involves a combination of mechanical trauma, increased pressure, and ischemic damage to the median nerve within the carpal tunnel. The diagnosis of CTS patients requires the respective medical professional to develop a case history associated with the characteristic signs of CTS. In addition, the doctor may question whether the patients use vibratory objects for their tasks, the parts of the arm where the sensations are felt, or if the patient may already have predisposing factors for CTS incidence. During the diagnosis of CTS, it is essential to note that other conditions may also provide similar symptoms to CTS, thus requiring vigorous diagnosis to assert the medical condition of the patients. Doctors use both non-surgical and surgical treatments when addressing CTS. Non-surgical treatments include wrist splinting, change of working position, medications, and the use of alternative non-vibrating equipment at work. On the other hand, surgical methods include open release and endoscopic surgeries. This review of literature has provided an overview of CTS with an emphasis on anatomy, epidemiology, risk factors, pathophysiology, stages of CTS, diagnosis, and management options.
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Affiliation(s)
- Alessia Genova
- Internal Medicine, Xavier University School of Medicine, Oranjestad, ABW
| | - Olivia Dix
- Internal Medicine, Xavier University School of Medicine, Oranjestad, ABW
| | - Asem Saefan
- Internal Medicine, Xavier University School of Medicine, Oranjestad, ABW
| | - Mala Thakur
- Internal Medicine, Xavier University School of Medicine, Oranjestad, ABW
| | - Abbas Hassan
- Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
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Çatalbaş N, Akkaya N, Atalay NS, Sahin F. Ultrasonographic imaging of the effects of continuous, pulsed or sham ultrasound treatments on carpal tunnel syndrome: A randomized controlled study. J Back Musculoskelet Rehabil 2019; 31:981-989. [PMID: 30223381 DOI: 10.3233/bmr-160652] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Clinical and electrophysiological effects of therapeutic ultrasound (US) were researched in many studies on patients with CTS with conflicting results. OBJECTIVE To assess the effects of continuous and pulsed US treatments by ultrasonographic imaging in addition to clinical and electrophysilogical parameters in patients with carpal tunnel syndrome (CTS). METHOD Fifty-four patients with idiopathic CTS were randomly divided into three groups. All patients used night splints for two weeks. In addition to splint therapy, continuous, pulsed or sham US treatments were applied to patients 10 min/session, 5 sessions/week for two weeks. Clinical situation (pain, hand function, strength), electrophysiological studies (motor distal latency, MDL, sensorial distal latency, SDL), and ultrasonographic area measurements of median nerve were evaluated. All evaluations were applied at pretreatment (baseline), posttreatment (2nd week) and in the 6th week. RESULTS Whereas significant differences were detected for clinical, functional and ultrasonographic imaging findings in each group in the 2nd week and 6th week compared to baseline (p< 0.0167 for both), no electrophysiological improvements were detected in pulsed-US (p> 0.0167) and only improvement for SDL in sham US group in the 2nd week evaluation (p< 0.0167). CONCLUSION According to the results of this study, continuous, pulsed or sham US treatments combined with splinting had similar effects on clinical, electrophysiological and ultrasonographic imaging improvements. Additionally, ultrasonographic imaging may be a preferable objective evaluation tool to prove the early posttreatment clinical improvements when electrophysiological changes could not be detected.
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Affiliation(s)
- Necdet Çatalbaş
- Department of Physical Medicine and Rehabilitation, Nobel Tıp Merkezi, Denizli, Turkey
| | - Nuray Akkaya
- Department of Physical Medicine and Rehabilitation, Pamukkale University, Denizli, Turkey
| | | | - Fusun Sahin
- Department of Physical Medicine and Rehabilitation, Pamukkale University, Denizli, Turkey
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Choi G, Wieland LS, Lee H, Sim H, Lee MS, Shin B. Acupuncture and related interventions for the treatment of symptoms associated with carpal tunnel syndrome. Cochrane Database Syst Rev 2018; 12:CD011215. [PMID: 30521680 PMCID: PMC6361189 DOI: 10.1002/14651858.cd011215.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Carpal tunnel syndrome (CTS) is a compressive neuropathic disorder at the level of the wrist. Acupuncture and other methods that stimulate acupuncture points, such as electroacupuncture, auricular acupuncture, laser acupuncture, moxibustion, and acupressure, are used in treating CTS. Acupuncture has been recommended as a potentially useful treatment for CTS, but its effectiveness remains uncertain. We used Cochrane methodology to assess the evidence from randomised and quasi-randomised trials of acupuncture for symptoms in people with CTS. OBJECTIVES To assess the benefits and harms of acupuncture and acupuncture-related interventions compared to sham or active treatments for the management of pain and other symptoms of CTS in adults. SEARCH METHODS On 13 November 2017, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, AMED, CINAHL Plus, DARE, HTA, and NHS EED. In addition, we searched six Korean medical databases, and three Chinese medical databases from inception to 30 April 2018. We also searched clinical trials registries for ongoing trials. SELECTION CRITERIA We included randomised and quasi-randomised trials examining the effects of acupuncture and related interventions on the symptoms of CTS in adults. Eligible studies specified diagnostic criteria for CTS. We included outcomes measured at least three weeks after randomisation. The included studies compared acupuncture and related interventions to placebo/sham treatments, or to active interventions, such as steroid nerve blocks, oral steroid, splints, non-steroidal anti-inflammatory drugs (NSAIDs), surgery and physical therapy. DATA COLLECTION AND ANALYSIS The review authors followed standard Cochrane methods. MAIN RESULTS We included 12 studies with 869 participants. Ten studies reported the primary outcome of overall clinical improvement at short-term follow-up (3 months or less) after randomisation. Most studies could not be combined in a meta-analysis due to heterogeneity, and all had an unclear or high overall risk of bias.Seven studies provided information on adverse events. Non-serious adverse events included skin bruising with electroacupuncture and local pain after needle insertion. No serious adverse events were reported.One study (N = 41) comparing acupuncture to sham/placebo reported change on the Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (SSS) at three months after treatment (mean difference (MD) -0.23, 95% confidence interval (CI) -0.79 to 0.33) and the BCTQ Functional Status Scale (FSS) (MD -0.03, 95% CI -0.69 to 0.63), with no clear difference between interventions; the evidence was of low certainty. The only dropout was due to painful acupuncture. Another study of acupuncture versus placebo/sham acupuncture (N = 111) provided no usable data.Two studies assessed laser acupuncture versus sham laser acupuncture. One study (N = 60), which was at low risk of bias, provided low-certainty evidence of a better Global Symptom Scale (GSS) score with active treatment at four weeks after treatment (MD 7.46, 95% CI 4.71 to 10.22; range of possible GSS scores is 0 to 50) and a higher response rate (risk ratio (RR) 1.59, 95% CI 1.14 to 2.22). No serious adverse events were reported in either group. The other study (N = 25) did not assess overall symptom improvement.One trial (N = 77) of conventional acupuncture versus oral corticosteroids provided very low-certainty evidence of greater improvement in GSS score (scale 0 to 50) at 13 months after treatment with acupuncture (MD 8.25, 95% CI 4.12 to 12.38) and a higher responder rate (RR 1.73, 95% CI 1.22 to 2.45). Change in GSS at two weeks or four weeks after treatment showed no clear difference between groups. Adverse events occurred in 18% of the oral corticosteroid group and 5% of the acupuncture group (RR 0.29, 95% CI 0.06 to 1.32). One study comparing electroacupuncture and oral corticosteroids reported a clinically insignificant difference in change in BCTQ score at four weeks after treatment (MD -0.30, 95% CI -0.71 to 0.10; N = 52).Combined data from two studies comparing the responder rate with acupuncture versus vitamin B12, produced a RR of 1.16 (95% CI 0.99 to 1.36; N = 100, very low-certainty evidence). No serious adverse events occurred in either group.One study of conventional acupuncture versus ibuprofen in which all participants wore night splints found very low-certainty evidence of a lower symptom score on the SSS of the BCTQ with acupuncture (MD -5.80, 95% CI -7.95 to -3.65; N = 50) at one month after treatment. Five people had adverse events with ibuprofen and none with acupuncture.One study of electroacupuncture versus night splints found no clear difference between the groups on the SSS of the BCTQ (MD 0.14, 95% CI -0.15 to 0.43; N = 60; very low-certainty evidence). Six people had adverse events with electroacupuncture and none with splints. One study of electroacupuncture plus night splints versus night splints alone presented no difference between the groups on the SSS of the BCTQ at 17 weeks (MD -0.16, 95% CI -0.36 to 0.04; N = 181, low-certainty evidence). No serious adverse events occurred in either group.One study comparing acupuncture plus NSAIDs and vitamins versus NSAIDs and vitamins alone showed no clear difference on the BCTQ SSS at four weeks (MD -0.20, 95% CI -0.86 to 0.46; very low-certainty evidence). There was no reporting on adverse events. AUTHORS' CONCLUSIONS Acupuncture and laser acupuncture may have little or no effect in the short term on symptoms of CTS in comparison with placebo or sham acupuncture. It is uncertain whether acupuncture and related interventions are more or less effective in relieving symptoms of CTS than corticosteroid nerve blocks, oral corticosteroids, vitamin B12, ibuprofen, splints, or when added to NSAIDs plus vitamins, as the certainty of any conclusions from the evidence is low or very low and most evidence is short term. The included studies covered diverse interventions, had diverse designs, limited ethnic diversity, and clinical heterogeneity. High-quality randomised controlled trials (RCTs) are necessary to rigorously assess the effects of acupuncture and related interventions upon symptoms of CTS. Based on moderate to very-low certainty evidence, acupuncture was associated with no serious adverse events, or reported discomfort, pain, local paraesthesia and temporary skin bruises, but not all studies provided adverse event data.
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Affiliation(s)
- Gwang‐Ho Choi
- Pusan National UniversitySchool of Korean MedicineBeom‐eu, MeulgeumYangsanKorea, South626‐870
| | - L Susan Wieland
- University of Maryland School of MedicineCenter for Integrative Medicine520 W. Lombard StreetBaltimoreMarylandUSA21201
| | - Hyangsook Lee
- Kyung Hee UniversityAcupuncture and Meridian Science Research Centre, College of Korean MedicineKyungheedaero 26Dongdaemun‐guSeoulKorea, South130‐701
| | - Hoseob Sim
- Pusan National UniversitySchool of Korean MedicineBeom‐eu, MeulgeumYangsanKorea, South626‐870
| | - Myeong Soo Lee
- Korea Institute of Oriental MedicineClinical Medicine Division461‐24 Jeonmin‐dong, Yuseong‐guDaejeonKorea, South34054
| | - Byung‐Cheul Shin
- School of Korean Medicine, Pusan National UniversityDepartment of Korean Rehabilitation MedicineBeom‐eu, MeulgeumYangsanKyungnamKorea, South626‐870
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Yao Y, Grandy E, Evans PJ, Seitz WH, Li ZM. Enhancement in median nerve mobility during radioulnar wrist compression in carpal tunnel syndrome patients. Clin Biomech (Bristol, Avon) 2018; 60:83-88. [PMID: 30336369 PMCID: PMC6252106 DOI: 10.1016/j.clinbiomech.2018.10.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/10/2018] [Accepted: 10/11/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Carpal tunnel syndrome is a compression neuropathy at the wrist associated with compromised median nerve mobility. The purpose of this study was to investigate the effects of radioulnar wrist compression on median nerve longitudinal mobility within the carpal tunnel in carpal tunnel syndrome patients as well as healthy subjects. METHODS Dynamic ultrasound images captured longitudinal median nerve motion in the carpal tunnel during radioulnar wrist compression force application in 11 healthy subjects and 11 carpal tunnel syndrome patients. FINDINGS We found that median nerve mobility was not significantly affected by radioulnar wrist compression in healthy subjects (P = 0.34), but improved by 10 N radioulnar wrist compression in carpal tunnel syndrome patients (P < 0.05). Analysis of segmental median nerve mobility in carpal tunnel syndrome patients showed significantly improved mobility in the proximal tunnel section under 10 N radioulnar wrist compression force condition compared to the no compression condition (P < 0.05). INTERPRETATION Moderate radioulnar wrist compression force application helps restore impaired median nerve mobility and may be effective in improve nerve function and symptoms associated with carpal tunnel syndrome.
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Affiliation(s)
- Yifei Yao
- Hand Research Laboratory, Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
| | - Emily Grandy
- Hand Research Laboratory, Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
| | - Peter J Evans
- Department of Orthopaedic Surgery, and Cleveland Clinic, Cleveland, OH, USA
| | - William H Seitz
- Department of Orthopaedic Surgery, and Cleveland Clinic, Cleveland, OH, USA
| | - Zong-Ming Li
- Hand Research Laboratory, Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA; Department of Orthopaedic Surgery, and Cleveland Clinic, Cleveland, OH, USA; Department of Physical Medicine and Rehabilitation, Cleveland Clinic, Cleveland, OH, USA.
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10
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Endoscopic transperineal pudendal nerve decompression: operative pudendoscopy. Surg Endosc 2018; 32:3720-3731. [DOI: 10.1007/s00464-018-6239-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/09/2018] [Indexed: 01/05/2023]
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Chung VCH, Ho RST, Liu S, Chong MKC, Leung AWN, Yip BHK, Griffiths SM, Zee BCY, Wu JCY, Sit RWS, Lau AYL, Wong SYS. Electroacupuncture and splinting versus splinting alone to treat carpal tunnel syndrome: a randomized controlled trial. CMAJ 2016; 188:867-875. [PMID: 27270119 PMCID: PMC5008933 DOI: 10.1503/cmaj.151003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 03/15/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The effectiveness of acupuncture for managing carpal tunnel syndrome is uncertain, particularly in patients already receiving conventional treatments (e.g., splinting). We aimed to assess the effects of electroacupuncture combined with splinting. METHODS We conducted a randomized parallel-group assessor-blinded 2-arm trial on patients with clinically diagnosed primary carpal tunnel syndrome. The treatment group was offered 13 sessions of electroacupuncture over 17 weeks. The treatment and control groups both received continuous nocturnal wrist splinting. RESULTS Of 181 participants randomly assigned to electroacupuncture combined with splinting (n = 90) or splinting alone (n = 91), 174 (96.1%) completed all follow-up. The electroacupuncture group showed greater improvements at 17 weeks in symptoms (primary outcome of Symptom Severity Scale score mean difference [MD] -0.20, 95% confidence interval [CI] -0.36 to -0.03), disability (Disability of Arm, Shoulder and Hand Questionnaire score MD -6.72, 95% CI -10.9 to -2.57), function (Functional Status Scale score MD -0.22, 95% CI -0.38 to -0.05), dexterity (time to complete blinded pick-up test MD -6.13 seconds, 95% CI -10.6 to -1.63) and maximal tip pinch strength (MD 1.17 lb, 95% CI 0.48 to 1.86). Differences between groups were small and clinically unimportant for reduction in pain (numerical rating scale -0.70, 95% CI -1.34 to -0.06), and not significant for sensation (first finger monofilament test -0.08 mm, 95% CI -0.22 to 0.06). INTERPRETATION For patients with primary carpal tunnel syndrome, chronic mild to moderate symptoms and no indication for surgery, electroacupuncture produces small changes in symptoms, disability, function, dexterity and pinch strength when added to nocturnal splinting. TRIAL REGISTRATION Chinese Clinical Trial Register no. ChiCTR-TRC-11001655 (www.chictr.org.cn/showprojen.aspx?proj=7890); subsequently deposited in the World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch/Trial2.aspx?TrialID=ChiCTR-TRC-11001655).
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Affiliation(s)
- Vincent C H Chung
- Jockey Club School of Public Health and Primary Care (Chong, Chung, Griffiths, Ho, Sit, Liu, Wong, Yip, Zee); Hong Kong Institute of Integrative Medicine (Chung, Lau, Sit, Wong, Wu); Department of Medicine and Therapeutics (Lau, Wu); School of Chinese Medicine (Leung), The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Institute of Global Health Innovation (Griffiths), Imperial College London, London, UK
| | - Robin S T Ho
- Jockey Club School of Public Health and Primary Care (Chong, Chung, Griffiths, Ho, Sit, Liu, Wong, Yip, Zee); Hong Kong Institute of Integrative Medicine (Chung, Lau, Sit, Wong, Wu); Department of Medicine and Therapeutics (Lau, Wu); School of Chinese Medicine (Leung), The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Institute of Global Health Innovation (Griffiths), Imperial College London, London, UK
| | - Siya Liu
- Jockey Club School of Public Health and Primary Care (Chong, Chung, Griffiths, Ho, Sit, Liu, Wong, Yip, Zee); Hong Kong Institute of Integrative Medicine (Chung, Lau, Sit, Wong, Wu); Department of Medicine and Therapeutics (Lau, Wu); School of Chinese Medicine (Leung), The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Institute of Global Health Innovation (Griffiths), Imperial College London, London, UK
| | - Marc K C Chong
- Jockey Club School of Public Health and Primary Care (Chong, Chung, Griffiths, Ho, Sit, Liu, Wong, Yip, Zee); Hong Kong Institute of Integrative Medicine (Chung, Lau, Sit, Wong, Wu); Department of Medicine and Therapeutics (Lau, Wu); School of Chinese Medicine (Leung), The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Institute of Global Health Innovation (Griffiths), Imperial College London, London, UK
| | - Albert W N Leung
- Jockey Club School of Public Health and Primary Care (Chong, Chung, Griffiths, Ho, Sit, Liu, Wong, Yip, Zee); Hong Kong Institute of Integrative Medicine (Chung, Lau, Sit, Wong, Wu); Department of Medicine and Therapeutics (Lau, Wu); School of Chinese Medicine (Leung), The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Institute of Global Health Innovation (Griffiths), Imperial College London, London, UK
| | - Benjamin H K Yip
- Jockey Club School of Public Health and Primary Care (Chong, Chung, Griffiths, Ho, Sit, Liu, Wong, Yip, Zee); Hong Kong Institute of Integrative Medicine (Chung, Lau, Sit, Wong, Wu); Department of Medicine and Therapeutics (Lau, Wu); School of Chinese Medicine (Leung), The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Institute of Global Health Innovation (Griffiths), Imperial College London, London, UK
| | - Sian M Griffiths
- Jockey Club School of Public Health and Primary Care (Chong, Chung, Griffiths, Ho, Sit, Liu, Wong, Yip, Zee); Hong Kong Institute of Integrative Medicine (Chung, Lau, Sit, Wong, Wu); Department of Medicine and Therapeutics (Lau, Wu); School of Chinese Medicine (Leung), The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Institute of Global Health Innovation (Griffiths), Imperial College London, London, UK
| | - Benny C Y Zee
- Jockey Club School of Public Health and Primary Care (Chong, Chung, Griffiths, Ho, Sit, Liu, Wong, Yip, Zee); Hong Kong Institute of Integrative Medicine (Chung, Lau, Sit, Wong, Wu); Department of Medicine and Therapeutics (Lau, Wu); School of Chinese Medicine (Leung), The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Institute of Global Health Innovation (Griffiths), Imperial College London, London, UK
| | - Justin C Y Wu
- Jockey Club School of Public Health and Primary Care (Chong, Chung, Griffiths, Ho, Sit, Liu, Wong, Yip, Zee); Hong Kong Institute of Integrative Medicine (Chung, Lau, Sit, Wong, Wu); Department of Medicine and Therapeutics (Lau, Wu); School of Chinese Medicine (Leung), The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Institute of Global Health Innovation (Griffiths), Imperial College London, London, UK
| | - Regina W S Sit
- Jockey Club School of Public Health and Primary Care (Chong, Chung, Griffiths, Ho, Sit, Liu, Wong, Yip, Zee); Hong Kong Institute of Integrative Medicine (Chung, Lau, Sit, Wong, Wu); Department of Medicine and Therapeutics (Lau, Wu); School of Chinese Medicine (Leung), The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Institute of Global Health Innovation (Griffiths), Imperial College London, London, UK
| | - Alexander Y L Lau
- Jockey Club School of Public Health and Primary Care (Chong, Chung, Griffiths, Ho, Sit, Liu, Wong, Yip, Zee); Hong Kong Institute of Integrative Medicine (Chung, Lau, Sit, Wong, Wu); Department of Medicine and Therapeutics (Lau, Wu); School of Chinese Medicine (Leung), The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Institute of Global Health Innovation (Griffiths), Imperial College London, London, UK
| | - Samuel Y S Wong
- Jockey Club School of Public Health and Primary Care (Chong, Chung, Griffiths, Ho, Sit, Liu, Wong, Yip, Zee); Hong Kong Institute of Integrative Medicine (Chung, Lau, Sit, Wong, Wu); Department of Medicine and Therapeutics (Lau, Wu); School of Chinese Medicine (Leung), The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Institute of Global Health Innovation (Griffiths), Imperial College London, London, UK
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Bahrami MH, Shahraeeni S, Raeissadat SA. Comparison between the effects of progesterone versus corticosteroid local injections in mild and moderate carpal tunnel syndrome: a randomized clinical trial. BMC Musculoskelet Disord 2015; 16:322. [PMID: 26502966 PMCID: PMC4623292 DOI: 10.1186/s12891-015-0752-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Accepted: 10/04/2015] [Indexed: 11/22/2022] Open
Abstract
Background The objective of this study was to compare the short-term effects of progesterone and corticosteroid local injections in the treatment of female patients with carpal tunnel syndrome. Methods A randomized clinical trial was used for this study, 60 hands with mild and moderate Carpal Tunnel Syndrome categorized in two groups were used for this study. Patients were treated with a single local injection of triamcinolone acetonide in one group and single local injection of 17-alpha hydroxy progesterone in the other group. Variables such as pain (based on Visual Analogue Scale), symptom severity and functional status (based on Bostone/Levine symptom severity and functional status scale) and nerve conduction study were evaluated before and 10 weeks after the treatments. Results Ten weeks after treatment, pain severity and median nerve sensory and motor latencies decreased while patients’ functional status increased meaningfully in both groups. However, there were no meaningful differences between two groups regarding mentioned variables. Pain severity was milder and duration of post-injection pain was shorter in the corticosteroid group. The rates of patient satisfaction were also meaningfully higher in the corticosteroid group. Conclusions Both treatments were effective in the short-term management of mild and moderate disease, clinically and electrophysiologically. There were no significant differences in therapeutic effects between two groups. Trial registration Current controlled trials IRCT2013101313442N4
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Affiliation(s)
- Mohammad Hassan Bahrami
- Physical Medicine and Rehabilitation research center, Shahid Beheshti University of Medical Sciences , Tehran, Iran.
| | - Shadi Shahraeeni
- Clinical research development center of Shahid Modarres hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Seyed Ahmad Raeissadat
- Clinical research development center of Shahid Modarres hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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EL-Badawy MAAF. Electrophysiological and clinical comparison of local steroid injection by means of proximal versus distal approach in patients with mild and moderate carpal tunnel syndrome. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2015. [DOI: 10.4103/1110-161x.163944] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Kim SD. Efficacy of tendon and nerve gliding exercises for carpal tunnel syndrome: a systematic review of randomized controlled trials. J Phys Ther Sci 2015; 27:2645-8. [PMID: 26357452 PMCID: PMC4563334 DOI: 10.1589/jpts.27.2645] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 04/24/2015] [Indexed: 12/30/2022] Open
Abstract
[Purpose] The purpose of this study was to assess the quality of evidence for the
efficacy of tendon and nerve gliding exercises in the management of carpal tunnel
syndrome. [Subjects and Methods] Four electronic databases were searched to identify
randomized controlled trials on the efficacy of tendon and nerve gliding exercises for
carpal tunnel syndrome. Quality assessment was conducted using the Cochrane risk of bias
tool. [Results] Four trials were identified and included in the review. The results of
critical appraisal of quality ranged between low and moderate risk of bias. The available
data could only be included as a narrative description. Symptom severity decreased and
functional status improved with combined treatment, involving a tendon or nerve gliding
exercise group plus conventional treatments, compared with the use of conventional
treatments alone. [Conclusion] Evidence from 4 randomized controlled trials suggests that
tendon and nerve gliding exercises, when combined with conventional treatments, may have a
favorable effect in patients with carpal tunnel syndrome. However, further randomized
controlled trials designed to assess the effect of tendon and nerve gliding exercises
alone are required to investigate the hypothesis that such exercises alleviate carpal
tunnel syndrome, and to confirm and further elucidate the efficacy of standardized
physical exercise programs in patients with carpal tunnel syndrome.
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Affiliation(s)
- Sang-Dol Kim
- Department of Nursing, College of Health Science, Kangwon National University, Republic of Korea
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Saint-Lary O, Rébois A, Mediouni Z, Descatha A. Carpal tunnel syndrome: primary care and occupational factors. Front Med (Lausanne) 2015; 2:28. [PMID: 26000277 PMCID: PMC4419845 DOI: 10.3389/fmed.2015.00028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 04/17/2015] [Indexed: 12/04/2022] Open
Abstract
Carpal tunnel syndrome (CTS) affects about 1% of working-aged people and is the commonest cause of hand pain in manual workers. CTS is a clinical diagnosis and does not warrant any further investigation in the presence of mild and suggestive CTS. Although the recommended non-surgical management is still a matter of debate, nocturnal splinting or steroid injection are recommended in most countries, with strong to moderate level of evidence for short-term efficacy. Patients with an uncertain diagnosis or severe symptoms, should undergo nerve conduction studies with referral to a hand specialist.
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Affiliation(s)
- Olivier Saint-Lary
- Department of Family Medicine, Faculty of Health Sciences Simone Veil, Université de Versailles Saint-Quentin-en-Yvelines , Montigny le Bretonneux , France ; Centre de Recherche en Épidémiologie et Santé des Populations (CESP) - INSERM U1018 Team 1 , Villejuif , France
| | - Arnaud Rébois
- Medical Home Primary Care of Montcient , Oinville , France
| | - Zakia Mediouni
- Occupational Health Unit/EMS (Samu92), Assistance Publique - Hôpitaux de Paris, Poincaré University Hospital , Garches , France ; Population-Based Epidemiologic Cohorts Unit, UMS 011, INSERM , Villejuif , France ; UMS 011 UMR-S 1168, Université de Versailles Saint-Quentin-en-Yvelines , Versailles , France
| | - Alexis Descatha
- Occupational Health Unit/EMS (Samu92), Assistance Publique - Hôpitaux de Paris, Poincaré University Hospital , Garches , France ; Population-Based Epidemiologic Cohorts Unit, UMS 011, INSERM , Villejuif , France ; UMS 011 UMR-S 1168, Université de Versailles Saint-Quentin-en-Yvelines , Versailles , France ; VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, U1168, INSERM , Villejuif , France
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Effects of yoga on cardiovascular disease risk factors: A systematic review and meta-analysis. Int J Cardiol 2014; 173:170-83. [DOI: 10.1016/j.ijcard.2014.02.017] [Citation(s) in RCA: 155] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 01/28/2014] [Accepted: 02/13/2014] [Indexed: 01/20/2023]
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Brienza M, Pujia F, Colaiacomo MC, Anastasio MG, Pierelli F, Di Biasi C, Andreoli C, Gualdi G, Valente GO. 3T diffusion tensor imaging and electroneurography of peripheral nerve: A morphofunctional analysis in carpal tunnel syndrome. J Neuroradiol 2014; 41:124-30. [DOI: 10.1016/j.neurad.2013.06.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 05/26/2013] [Accepted: 06/04/2013] [Indexed: 10/26/2022]
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Minchin P, Spirtos M. Investigation of the conservative management of mallet injury in Irish acute hospitals. HAND THERAPY 2012. [DOI: 10.1258/ht.2012.012004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction Mallet injury is a commonly treated hand injury in acute hospitals. While there is much literature regarding the various treatment options and outcomes, no studies were found that describe the management of this injury across a national health service. This study describes how mallet injury is managed within the acute hospital system in Ireland. An understanding of the current system of service provision is essential for future service development in this area. Method Emergency and occupational therapy departments in the 29 acute case-mix hospitals in Ireland were contacted by telephone and postal questionnaire with 47 respondents participating in the study. Descriptive statistics are used to present the results. Results Results indicate that accessing acute hospital-based services for the conservative management of mallet injury typically follows a predictable pathway, but can result in delays and disruption to treatment for the patient. There is little evidence of direct referral from the emergency department to the occupational therapist which, when compared with published literature, would represent the most efficient and optimum care pathway for the patient. The choice of splint used by both the emergency and occupational therapy departments differs, but treatment provided is in line with available evidence-based practice. Conclusions This preliminary study provides a basis for future service development in the acute management of mallet injury, by describing how treatment is currently provided nationally. Recommendations for further investigation have been made, and the need for audit and outcome measurement has been highlighted. The development of therapy-led services in Ireland is proposed, to improve efficiency and quality of service provision in the conservative management of mallet injury.
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Affiliation(s)
- Paula Minchin
- Occupational Therapy Department, Adelaide & Meath Hospital, Dublin, Ireland
| | - Michelle Spirtos
- Discipline of Occupational Therapy, Trinity College, Dublin, Ireland
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A randomized sham-controlled trial of a neurodynamic technique in the treatment of carpal tunnel syndrome. J Orthop Sports Phys Ther 2009; 39:709-23. [PMID: 19801812 PMCID: PMC2864088 DOI: 10.2519/jospt.2009.3117] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Randomized, controlled trial. OBJECTIVES To assess the believability of a novel sham intervention for a neurodynamic technique (NDT) in participants with signs and symptoms of carpal tunnel syndrome (CTS). Additionally, we wished to assess a potential mechanism of NDT (hypoalgesia) and to compare outcomes related to clinical pain and upper extremity disability between NDT and a sham intervention. BACKGROUND Preliminary evidence suggests that NDT is effective in the treatment of CTS. A sham-controlled study is lacking from the literature and could provide insight to the efficacy of NDT, as well as the corresponding mechanisms. METHODS Participants with signs and symptoms consistent with CTS provided baseline measures of expectation, clinical pain intensity, upper extremity disability, and experimental pain sensitivity. Participants were then randomly assigned to receive either a NDT known to anatomically stress the median nerve or a sham technique intended to minimize stress to the median nerve. Following brief exposure to the assigned technique, expectation was reassessed to observe for group-dependent changes. Participants received the assigned intervention over 3 weeks. Additionally, all participants received a prefabricated wrist splint for their involved hands, with instructions to sleep in the splint and to wear it during painful activities when awake. Following 3 weeks of the assigned intervention and splint wear, baseline measures were reassessed and participants were asked which intervention they believed they had received. RESULTS Forty females agreed to participate. Expectations for pain relief and perceived group assignment were similar between the groups. Within-session decreases in clinical pain intensity and pressure pain sensitivity were observed independent of group assignment. Reduction of temporal summation was observed only in participants receiving NDT. Significant improvements in clinical pain intensity and upper extremity disability were observed at 3 weeks, independent of group assignment. CONCLUSION The sham intervention was successful in blinding the participants. Immediate changes in pain sensitivity and intensity and 3-week changes in clinical pain intensity and upper extremity disability associated with NDT were equivalent to a sham intervention to which the participants were adequately blinded. Conversely, reduction of temporal summation was only observed in participants receiving the NDT, suggesting the potential of a favorable neurophysiological effect.
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The cost-effectiveness of nonsurgical versus surgical treatment for carpal tunnel syndrome. J Hand Surg Am 2009; 34:1193-200. [PMID: 19700068 DOI: 10.1016/j.jhsa.2009.04.034] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2008] [Revised: 03/25/2009] [Accepted: 04/22/2009] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare direct costs and results for patients with electrodiagnostically proven carpal tunnel syndrome treated with surgery versus nonsurgical care. METHODS There is a retrospective study of 120 patients divided into 2 groups: subjects in group 1 had chosen nonsurgical treatment, whereas subjects in group 2 had chosen surgery with no nonsurgical treatment. Patients were matched on age, gender, severity of nerve conduction abnormalities, body mass index, smoking history, job category, and insurance coverage. Direct cost of care was measured. An incremental cost-utility ratio was calculated to compare costs between the different management strategies. RESULTS Group 1 follow-up averaged 13 +/- 5 months compared to 12 +/- 2 months for group 2. Steroid injections were used in 18 patients in group 1. Thirty-two patients in group 1 elected to have surgery during the follow-up period. Cost of care averaged $3335 +/- $2097 in group 1 and $3068 +/- $983 in group 2. CONCLUSIONS The direct cost of nonsurgical care of confirmed carpal tunnel syndrome did not show a significant difference from that of surgical treatment without preoperative splinting or therapy. The incremental cost-utility ratio for carpal tunnel surgery was favorable. Surgery, rather than nonsurgical care, should be considered as the initial form of treatment when patients are diagnosed with carpal tunnel syndrome that is confirmed by nerve conduction studies, as this provides symptom resolution with a favorable cost analysis. TYPE OF STUDY/LEVEL OF EVIDENCE Economic and Decision Analysis III.
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Different nerve-gliding exercises induce different magnitudes of median nerve longitudinal excursion: an in vivo study using dynamic ultrasound imaging. J Orthop Sports Phys Ther 2009; 39:164-71. [PMID: 19252262 DOI: 10.2519/jospt.2009.2913] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Controlled laboratory study using single-group, within-subject comparisons. OBJECTIVES To determine in an in vivo study whether different types of nerve-gliding exercises are associated with different amounts of longitudinal nerve excursion. BACKGROUND Different types of nerve-gliding exercises have been proposed. It is assumed that different exercises produce different amounts of excursion and strain in the peripheral nervous system. Although this has been confirmed in cadaveric experiments, in vivo studies are lacking. METHODS High-resolution ultrasound was used to measure longitudinal excursion of the median nerve in the upper arm during 6 different nerve-gliding exercises. Nerve mobilization techniques that involved the elbow and neck were evaluated in 15 asymptomatic volunteers (mean +/- SD age, 30 +/- 8 years). Nerve longitudinal excursion was calculated using a frame-by-frame cross-correlation analysis. A repeated-measures analysis of variance was used to analyze the data. RESULTS Different exercises induced different amounts of longitudinal nerve excursion (P<.0001). The "sliding technique" was associated with the largest excursion (mean +/- SD, 10.2 +/- 2.8 mm; P = .0001). The amount of nerve movement associated with the "tensioning technique" (mean +/- SD, 1.8 +/- 4.0 mm) was smaller than the nerve excursion induced with individual movements of the neck or elbow (mean +/- SD range, -3.4 +/- 0.9 to 5.6 +/- 2.1 mm; P = .0001). CONCLUSION These findings confirm that different types of neurodynamic techniques have different mechanical effects on the nervous system. Recognition of these differences may assist in the selection of treatment techniques. Having demonstrated differences in mechanical effects, future research will have to evaluate whether these different techniques are also associated with different physiological and therapeutic effects.
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Evaluation of the clinical efficacy of conservative treatment in the management of carpal tunnel syndrome. Adv Ther 2009; 26:107-16. [PMID: 19165436 DOI: 10.1007/s12325-008-0134-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Carpal tunnel syndrome (CTS) is impingement of the median nerve at the wrist. The aim of this study was to compare the effectiveness of tendon and nerve gliding exercises with standard conservative treatment (SCT), which consists of splinting and local steroid injections, in the treatment of CTS. METHODS This study was a prospective, randomized, single-blind trial. Patients were randomized into three groups: treatment with SCT (Group 1); SCT and tendon and nerve gliding exercises (Group 2); tendon and nerve gliding exercises only (Group 3). A symptom total point score was obtained from five symptoms: hand pain, tingling, numbness, nocturnal numbness, and interrupted sleep. The functional status of the hand was determined by assessing seven daily living activities: writing, buttoning clothes, gripping a telephone receiver, opening jars, doing housework, carrying grocery bags, and bathing. Standard physical examinations (Tinel's test, Phalen's test, reverse Phalen's test, and the compression test) were also performed. RESULTS A total of 111 patients who were diagnosed with intermediate-stage CTS were included in the study. At the end of treatment, significant improvements in symptoms and functionality were detected in all groups. However, the recovery of patients in Groups 1 (n=41) and 2 (n=35) were found to be significantly greater than that of patients in Group 3 (n=35; P<0.001). Patient satisfaction was investigated a mean of 11 months after treatment. Percentages of asymptomatic patients in Group 1 and Group 2 were significantly higher than in Group 3 (P=0.02 and P=0.04, respectively). CONCLUSION In the intermediate stage of CTS, SCT was an effective treatment to improve symptoms and functional status. Tendon and nerve gliding exercises alone were inferior to either SCT alone or SCT in combination with gliding exercises.
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A Storey P, Dipcot HD, J Bradley M, Couchman L, D Burke F. Audit of a Therapist-led Clinic for Carpal Tunnel Syndrome in Primary Care. ACTA ACUST UNITED AC 2008. [DOI: 10.1177/175899830801300301] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
An audit was designed to evaluate the effect on waiting times, did not attend (DNA) rates and quality of clinical management of a hand therapist-led clinic for Carpal Tunnel Syndrome (CTS) in Primary Care, and to investigate whether the clinic acted as an effective threshold mechanism for the Pulvertaft Hand Centre consultant clinics. Following a period of training with a senior consultant at the Pulvertaft Centre, an experienced hand therapist from the Centre worked out in Primary Care seeing patients with a provisional diagnosis of CTS who had been referred directly from General Practitioners (GPs). The referrals were assisted by the use of a local referral protocol. Tinel's and Phalen's tests were performed and areas of sensory loss were documented. A Levine Questionnaire was completed by the patient at an initial appointment and subsequently at review four to eight weeks later. Grip and pinch measurements were taken using a Jamar® Dynamometer. Mild and moderate CTS can be effectively managed by a community-based Hand Therapy Clinic. Forty five percent of GP-referred CTS patients were successfully managed without referral onto the Hand Centre and did not require further treatment for CTS in the subsequent two years. The consultation length was 30 minutes per patient at the therapist-led clinic, compared with 15 minutes at the Hand Centre. Waiting times were reduced from 90 to 20 days, and the clinic had a low (3%) DNA rate. Wrist splints were expertly chosen and fitted and patients were educated and empowered about their condition. The Hand Therapy Clinic acted as a useful threshold mechanism for Tertiary Care Hand Centre CTS referrals, removing 46% of CTS referrals from the Hand Centre clinics. The proportion of Hand Clinic-referred patients requiring carpal tunnel decompression (CTD) was therefore increased to 62% from 33%. This community-based, hand therapist-led clinic for CTS management is consistent with current Health Service initiatives.
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Affiliation(s)
- Philip A Storey
- Pulvertaft Hand Centre, Derbyshire Royal Infirmary, Derby, UK
| | | | - Mary J Bradley
- Pulvertaft Hand Centre, Derbyshire Royal Infirmary, Derby, UK
| | - Louise Couchman
- Pulvertaft Hand Centre, Derbyshire Royal Infirmary, Derby, UK
| | - Frank D Burke
- Pulvertaft Hand Centre, Derbyshire Royal Infirmary, Derby, UK
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Coppieters MW, Butler DS. Do ‘sliders’ slide and ‘tensioners’ tension? An analysis of neurodynamic techniques and considerations regarding their application. ACTA ACUST UNITED AC 2008; 13:213-21. [PMID: 17398140 DOI: 10.1016/j.math.2006.12.008] [Citation(s) in RCA: 199] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2006] [Revised: 12/08/2006] [Accepted: 12/15/2006] [Indexed: 10/23/2022]
Abstract
Despite the high prevalence of carpal tunnel syndrome and cubital tunnel syndrome, the quality of clinical practice guidelines is poor and non-invasive treatment modalities are often poorly documented. The aim of this cadaveric biomechanical study was to measure longitudinal excursion and strain in the median and ulnar nerve at the wrist and proximal to the elbow during different types of nerve gliding exercises. The results confirmed the clinical assumption that 'sliding techniques' result in a substantially larger excursion of the nerve than 'tensioning techniques' (e.g., median nerve at the wrist: 12.6 versus 6.1mm, ulnar nerve at the elbow: 8.3 versus 3.8mm), and that this larger excursion is associated with a much smaller change in strain (e.g., median nerve at the wrist: 0.8% (sliding) versus 6.8% (tensioning)). The findings demonstrate that different types of nerve gliding exercises have largely different mechanical effects on the peripheral nervous system. Hence different types of techniques should not be regarded as part of a homogenous group of exercises as they may influence neuropathological processes differently. The findings of this study and a discussion of possible beneficial effects of nerve gliding exercises on neuropathological processes may assist the clinician in selecting more appropriate nerve gliding exercises in the conservative and post-operative management of common neuropathies.
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Affiliation(s)
- Michel W Coppieters
- Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, QLD 4072, St. Lucia Brisbane, Australia.
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Burke FD, Bradley MJ, Sinha S, Wilgis EFS, Dubin NH. Primary care management of patients with carpal tunnel syndrome referred to surgeons: are non-operative interventions effectively utilised? Postgrad Med J 2007; 83:498-501. [PMID: 17621622 PMCID: PMC2600099 DOI: 10.1136/pgmj.2007.058206] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM To investigate the non-operative primary care management (splintage, task modification advice, steroid injections and oral medications) of carpal tunnel syndrome before patients were referred to a hand surgeon for decompression. DESIGN AND SETTING Preoperative data were obtained on age, gender, body mass index, employment, symptom duration, and preoperative clinical stage for patients undergoing carpal tunnel decompression (263 in the USA, 227 in the UK). RESULTS Primary care physicians made relatively poor use of beneficial treatment options with the exception of splintage in the US (73% of cases compared with 22.8% in the UK). Steroid injections were used in only 22.6% (US) and 9.8% (UK) of cases. Task modification advice was almost never given. Oral medication was employed in 18.8% of US cases and 8.9% of UK cases. CONCLUSIONS This study analyses the non-operative modalities available and suggests that there is scope for more effective use of non-operative treatment before referral for carpal tunnel decompression.
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Affiliation(s)
- Frank D Burke
- The Pulvertaft Hand Centre, Derbyshire Royal Infirmary, Derby, UK
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Burke FD, Bradley MJ. A proposal justifying an alternative referral practice from primary care for three common hand surgery diagnoses. Postgrad Med J 2007; 83:616-7. [PMID: 17916868 DOI: 10.1136/pgmj.2007.060723] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Rasch RF. Evaluation of the Patient with Hand Pain and Numbness: Carpal Tunnel Syndrome. J Nurse Pract 2007. [DOI: 10.1016/j.nurpra.2007.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Coppieters MW, Alshami AM. Longitudinal excursion and strain in the median nerve during novel nerve gliding exercises for carpal tunnel syndrome. J Orthop Res 2007; 25:972-80. [PMID: 17415752 DOI: 10.1002/jor.20310] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Nerve and tendon gliding exercises are advocated in the conservative and postoperative management of carpal tunnel syndrome (CTS). However, traditionally advocated exercises elongate the nerve bedding substantially, which may induce a potentially deleterious strain in the median nerve with the risk of symptom exacerbation in some patients and reduced benefits from nerve gliding. This study aimed to evaluate various nerve gliding exercises, including novel techniques that aim to slide the nerve through the carpal tunnel while minimizing strain ("sliding techniques"). With these sliding techniques, it is assumed that an increase in nerve strain due to nerve bed elongation at one joint (e.g., wrist extension) is simultaneously counterbalanced by a decrease in nerve bed length at an adjacent joint (e.g., elbow flexion). Excursion and strain in the median nerve at the wrist were measured with a digital calliper and miniature strain gauge in six human cadavers during six mobilization techniques. The sliding technique resulted in an excursion of 12.4 mm, which was 30% larger than any other technique (p<or=0.0002). Strain also differed between techniques (p<or=0.00001), with minimal peak values for the sliding technique. Nerve gliding associated with wrist movements can be considerably increased and nerve strain substantially reduced by simultaneously moving neighboring joints. These novel nerve sliding techniques are biologically plausible exercises for CTS that deserve further clinical evaluation.
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Affiliation(s)
- Michel W Coppieters
- Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, QLD 4072 St. Lucia (Brisbane), Australia.
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Wildin C, Dias JJ, Heras-Palou C, Bradley MJ, Burke FD. Trends in elective hand surgery referrals from primary care. Ann R Coll Surg Engl 2006; 88:543-6. [PMID: 17059713 PMCID: PMC1963740 DOI: 10.1308/003588406x117070] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Two prospective audits of activity in a hand unit were performed, in 1989-1990 and during 2000-2001, to identify trends in elective hand surgery referrals from primary care. PATIENTS AND METHODS Two 6-month prospective audits of activity in a hand unit were performed, including elective referrals from primary care. Data were collected on all in-district referrals with elective hand disorders. Cross boundary flow was identified to permit assessment of changes in referrals by diagnosis over a decade. RESULTS There was a 36% increase in health authority referrals for elective hand surgery over the decade (from 289 to 392 per 100,000 of population per year). The number of elective hand surgery operations rose 34% over the decade (from 149 to 199 operations per 100,000 of population per year). Carpal tunnel syndrome (the commonest reason for elective referral) almost doubled (from 59.7 to 112 per 100,000 of population per year). Referrals for ganglion, the second most common elective referral, rose modestly. Referrals for osteoarthritis (commonly basal thumb arthritis) almost trebled over the decade to become the fourth commonest condition referred to the hand unit (from 12.7 to 34 per 100,000 of population per year). Referrals for Dupuytrens disease, trigger finger and rheumatoid arthritis were relatively unchanged over the decade. Congenital hand referrals are uncommon but doubled during the decade. CONCLUSIONS Hand surgery referrals rose by 36% over the decade. Analysis of the commoner conditions referred reveal a high prevalence within the community with the possibility of increased referrals in years to come.
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Affiliation(s)
- Clair Wildin
- Department of Hand Surgery, Leicester Royal Infirmary, Leicester, UK
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Baysal O, Altay Z, Ozcan C, Ertem K, Yologlu S, Kayhan A. Comparison of three conservative treatment protocols in carpal tunnel syndrome. Int J Clin Pract 2006; 60:820-8. [PMID: 16704676 DOI: 10.1111/j.1742-1241.2006.00867.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The aim of this study was to investigate and compare the therapeutic effect of three different combinations in the conservative treatment of carpal tunnel syndrome (CTS) by means of clinical and electrophysiological studies. The combinations included tendon- and nerve-gliding exercises in combination with splinting, ultrasound treatment in combination with splinting and the combination of ultrasound, splinting, tendon- and nerve-gliding exercises. A total 28 female patients (56 wrists) with clinical and electrophysiologic evidence of bilateral CTS were studied. In all patient groups, the treatment combinations were significantly effective immediately and 8 weeks after the treatment. The results of the long-term patient satisfaction questionnaire revealed that symptomatic improvement is more prominent in the group treated with splinting, exercise and ultrasound therapy combination. Our results suggest that a combination of splinting, exercise and ultrasound therapy is a preferable and an efficacious conservative type of treatment in CTS.
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Affiliation(s)
- O Baysal
- Department of Physical Medicine and Rehabilitation, Inonu University, Malatya, Turkey.
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Dubert T, Racasan O. A reliable technique for avoiding the median nerve during carpal tunnel injections. Joint Bone Spine 2005; 73:77-9. [PMID: 16242987 DOI: 10.1016/j.jbspin.2005.02.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2004] [Accepted: 02/23/2005] [Indexed: 11/16/2022]
Abstract
Carpal tunnel injections are widely performed for diagnostic and therapeutic purposes. Injury to the median nerve is a serious and fairly common complication. There is no consensus regarding the safest injection site. The objective of this study was to determine the safest injection site based on anatomical data. During 124 endoscopic procedures for median nerve release at the carpal tunnel, we measured the distances separating the median nerve, palmaris longus (PL), flexor carpi radialis (FCR), and flexor carpi ulnaris 1 cm proximal to the wrist crease. The edge of the median nerve extended medially beyond the PL tendon in 82 (88%) hands. Thus, needle insertion within 1 cm of either edge of the PL tendon may cause median nerve injury; with injection sites located further toward the medial edge, the ulnar pedicle may be at risk. Consequently, we recommend that carpal tunnel injections be performed through the FCR tendon.
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Affiliation(s)
- Thierry Dubert
- Clinique La Francilienne, avenue de l'Hôtel de Ville, Pontault-Combault, France.
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Abstract
The assessment and conservative interventions in patients with carpal tunnel syndrome (CTS) are described in this paper. Information about surgical procedures and postoperative care has also been included. It is difficult to make definitive conclusions about the literature regarding success of treatment for CTS due to variations in outcome measures, severity of CTS, and inconsistencies in duration, dosage, and follow-up time for interventions. Based on what is known to date, this author recommends that patients with mild or moderate CTS be provided with a conservative program of splinting the wrist in neutral for nocturnal wear. In addition, intermittent exercise (nerve-gliding exercises) and activity modification, including avoidance of protracted periods of sustained gripping activities and awkward wrist positions, can be useful. This conservative program may be complemented by pain-relieving modalities during times of activity and supplemental participation in other exercise such as yoga. If symptoms are not relieved to the satisfaction of the patient, or they recur, then it is incumbent upon the therapist to refer the patient to a hand surgeon for injection or possible surgical decompression.
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