Nonsurgical Treatment of Carpal Tunnel Syndrome
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EVIDENCE-BASED MEDICINE Nonsurgical Treatment of Carpal Tunnel Syndrome Brent Graham, MD THE PATIENT A 45-year-old woman presents with a complaint of intermittent numbness and tingling in the right hand that started spontaneously about 6 months previously and bothers her more at night than during the day. The numbness wakes her from sleep nearly every night. The sensory disturbance involves the index, middle, and ring fingers and is most pronounced in the middle finger. There is no atrophy of the intrinsic musculature, including the thenar eminence, and she has strong pal- mar abduction of the thumb. Two-point discrimination is normal. There is a positive Tinel sign to percussion over the median nerve at the carpal tunnel. The Phalen test is positive. Her family physician has already ob- tained electrodiagnostic tests, which show that median nerve sensory conduction velocity is decreased across the carpal tunnel. At this point, the patient has not received any treatment for these symptoms. THE QUESTION What is the best nonsurgical treatment for carpal tunnel syndrome (CTS)? CURRENT OPINION A spectrum of treatment options can be considered for the patient with CTS in whom there has been no treat- ment thus far or in whom surgical management is not necessarily indicated. THE EVIDENCE Before starting treatment, the objective of a therapeutic intervention should be considered. Where the goal is to return to activities without symptoms as soon as possi- ble, it is possible that surgical decompression as a first treatment might be justified, although the literature does not contain any direct comparison with nonsurgical management where return to activities is the principal outcome measure. Gerritsen et al. 1 have shown that clinical improvement with surgical treatment is better than splinting at 3 months, 6 months, and 1 year. Garland et al. 2 have also reported this finding at 1-year follow-up. Carpal tunnel release has also been found to be superior to local steroid injection at 3- and 6-month follow-up. 3,4 A substantial proportion of patients initially treated with nonsurgical measures will eventually have surgery, and so although a pe- riod of nonsurgical treatment is unlikely to reduce the effect of surgery when it is eventually performed (provided that atrophy, static numbness, or weakness of palmar abduction do not become established), a delay in full resolution of the symptoms is inevitable if nonsurgical measures are not immediately helpful. Options for nonsurgical treatment of CTS A wide range of nonsurgical treatments have been sug- gested for CTS, including various therapy modalities, lifestyle modifications, and drug interventions; how- ever, few of these have been evaluated in studies that could be considered at least level II evidence. Those studies that are level II and above use a variety of outcomes to measure the effects of the treatment of interest. The length of time considered necessary to observe an effect also varies over a wide range, from as little as 2 weeks to as long as 6 months. Splinting: Among nonsurgical treatments, splinting is the most familiar.A number of level II studies, includ- ing those of Manente et al. 5 and Premoselli et al., 6 have compared splinting to no treatment. The main findings of both studies were that splinting was more effective than no treatment in improving symptom severity and functional status for at least 3 months. The results after this time could not be evaluated because neither study had sufficient power. Two additional studies have looked at full-time splinting compared with nocturnal splinting alone 7 and at the value of adding nerve and tendon gliding exercises to splinting. 8 No clear dif- ferences were found, but both of these studies were underpowered. Other therapy modalities: Ultrasound has been found to be an effective treatment in at least 2 studies. The clearest From the University of Toronto, University Health Network Hand Program, Toronto Western Hospital, Toronto, Ontario, Canada. Received for publication January 6, 2009; accepted in revised form January 7, 2009. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Brent Graham, MD, Toronto Western Hospital, 399 Bathurst Street, East Wing 2-425, Toronto, Ontario M5T 2S8, Canada; e-mail: [email protected]. 0363-5023/09/34A03-0024$36.00/0 doi:10.1016/j.jhsa.2009.01.010 Evidence-Based Medicine © Published by Elsevier, Inc. on behalf of the ASSH. 531
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Transcript of Nonsurgical Treatment of Carpal Tunnel Syndrome
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EVIDENCE-BASEDMEDICINE
Nonsurgical Treatment of Carpal Tunnel Syndrome
Brent Graham, MD
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HE PATIENT45-year-old woman presents with a complaint of
ntermittent numbness and tingling in the right hand thattarted spontaneously about 6 months previously andothers her more at night than during the day. Theumbness wakes her from sleep nearly every night. Theensory disturbance involves the index, middle, anding fingers and is most pronounced in the middlenger. There is no atrophy of the intrinsic musculature,
ncluding the thenar eminence, and she has strong pal-ar abduction of the thumb. Two-point discrimination
s normal. There is a positive Tinel sign to percussionver the median nerve at the carpal tunnel. The Phalenest is positive. Her family physician has already ob-ained electrodiagnostic tests, which show that medianerve sensory conduction velocity is decreased acrosshe carpal tunnel. At this point, the patient has noteceived any treatment for these symptoms.
HE QUESTIONhat is the best nonsurgical treatment for carpal tunnel
yndrome (CTS)?
URRENT OPINIONspectrum of treatment options can be considered for
he patient with CTS in whom there has been no treat-ent thus far or in whom surgical management is not
ecessarily indicated.
HE EVIDENCEefore starting treatment, the objective of a therapeutic
ntervention should be considered. Where the goal is toeturn to activities without symptoms as soon as possi-le, it is possible that surgical decompression as a firstreatment might be justified, although the literature does
From the University of Toronto, University Health Network Hand Program, Toronto Western Hospital,Toronto, Ontario, Canada.
Received for publication January 6, 2009; accepted in revised form January 7, 2009.
No benefits in any form have been received or will be received related directly or indirectly to thesubject of this article.
Corresponding author: Brent Graham, MD, Toronto Western Hospital, 399 Bathurst Street, EastWing 2-425, Toronto, Ontario M5T 2S8, Canada; e-mail: [email protected].
0363-5023/09/34A03-0024$36.00/0
adoi:10.1016/j.jhsa.2009.01.010
ot contain any direct comparison with nonsurgicalanagement where return to activities is the principal
utcome measure. Gerritsen et al.1 have shown thatlinical improvement with surgical treatment is betterhan splinting at 3 months, 6 months, and 1 year.arland et al.2 have also reported this finding at-year follow-up. Carpal tunnel release has also beenound to be superior to local steroid injection at 3-nd 6-month follow-up.3,4 A substantial proportionf patients initially treated with nonsurgical measuresill eventually have surgery, and so although a pe-
iod of nonsurgical treatment is unlikely to reduce theffect of surgery when it is eventually performedprovided that atrophy, static numbness, or weaknessf palmar abduction do not become established), aelay in full resolution of the symptoms is inevitablef nonsurgical measures are not immediately helpful.
ptions for nonsurgical treatment of CTS
wide range of nonsurgical treatments have been sug-ested for CTS, including various therapy modalities,ifestyle modifications, and drug interventions; how-ver, few of these have been evaluated in studies thatould be considered at least level II evidence. Thosetudies that are level II and above use a variety ofutcomes to measure the effects of the treatment ofnterest. The length of time considered necessary tobserve an effect also varies over a wide range, from asittle as 2 weeks to as long as 6 months.
plinting: Among nonsurgical treatments, splinting ishe most familiar.A number of level II studies, includ-ng those of Manente et al.5 and Premoselli et al.,6 haveompared splinting to no treatment. The main findingsf both studies were that splinting was more effectivehan no treatment in improving symptom severity andunctional status for at least 3 months. The results afterhis time could not be evaluated because neither studyad sufficient power. Two additional studies haveooked at full-time splinting compared with nocturnalplinting alone7 and at the value of adding nerve andendon gliding exercises to splinting.8 No clear dif-erences were found, but both of these studies werenderpowered.
ther therapy modalities: Ultrasound has been found to be
n effective treatment in at least 2 studies. The clearest© Published by Elsevier, Inc. on behalf of the ASSH. � 531
532 NONSURGICAL TREATMENT OF CARPAL TUNNEL SYNDROME
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of these was the study of Ebenbichler et al.,9 whichcompared ultrasound to placebo. With symptom sever-ity as the primary outcome measure, there was anadvantage to treatment with ultrasound at 7 weeks andat 6 months. A study by Bakhtiary et al.10 comparedultrasound to laser treatment and identified an advan-tage to ultrasound both at 3 weeks and at 7 weeks.
Other therapy modalities have either been shown tohave no effect or have been evaluated only in under-powered studies. Michlovitz et al.11 found that “heattherapy” was not as effective as an oral placebo inimproving a variety of measures of hand function, butthe outcomes were measured only over a 3- to 5-dayperiod. Treatments such as therapeutic touch, chiroprac-tic, and iontophoresis have not been studied in largeenough studies to allow an evaluation of any effect ofthese interventions.
Oral steroid treatment: Hui et al.12 studied the effects onCTS symptoms of a pulse of oral steroids. In both theimmediate (2 weeks) and medium term (8 weeks), therewas an advantage to oral steroids compared with pla-cebo. This was also the finding of Chang et al.13 withshorter follow-up. This study also showed that oralsteroids are more effective than diuretic treatment overa 2- to 4-week period of observation. Despite the pos-itive effect on CTS symptoms that was observed withoral steroids, the long-term risk of even a short exposuremight raise some concerns.14 Neither study followedthe patients in their sample beyond a maximum of 8weeks and thus could not evaluate the risk of steroid-related complications or the long-term effectiveness ofthis treatment.
Injection of corticosteroids: Steroid injection into the carpalcanal, another commonly used nonsurgical treatmentfor CTS, has been evaluated in a number of level IIstudies. In short-term studies, Armstrong et al.15 andDammers et al.16 have both shown an advantage com-pared to placebo over a 2- to 4-week period. Localsteroid injection has also been shown to be superior tooral steroids over a 3-month period of observation.17 At1-month follow-up, local steroid injection has also beenshown to be more effective than systemic steroid ad-ministration.18 Steroid injection combined with splint-ing has also been shown to be superior to splintingalone at 6 months follow-up.19
Other drugs: Treatment with diuretics or with nonsteroi-dal anti-inflammatory drugs (NSAIDs) has been rela-tively common, especially among primary care physi-cians; however, evidence to support this approach is
lacking. Chang et al.13 studied diuretic treatment com-JHS �Vol A, M
pared with placebo and NSAIDs compared with pla-cebo. The patients were observed for only 4 weeks, andthe study was not sufficiently powered to allow a com-parison to be made.
Vitamin B has been compared to placebo and hasbeen shown to improve “movement discomfort” at 12weeks, but this study was not adequately powered toassess the symptom of “nocturnal discomfort” at thesame follow-up.20
Other noteworthy nonsurgical measures: There have been nolevel II studies evaluating the effect of workplace orother activity modification; regular exercise or stretch-ing; massage therapy; yoga; treatments with magnets,acupuncture, or laser (including “cold laser”); weightreduction; cognitive behavioral therapy; or smokingcessation.
SHORTCOMINGS OF THE EVIDENCE ANDDIRECTIONS FOR FUTURE RESEARCHMost clinical studies relating to CTS, whether they areconcerned with cause, treatment, or outcome, are hin-dered by the absence of a consistent approach to diag-nosis. Although the case described here is close to theclassic presentation for this condition, there are manyinstances of median nerve compression that might notnecessarily correspond to this. Nonetheless, consistencyin diagnostic practices is fundamental to ensuring thatpatients that are included in clinical research studiesmeet criteria for having the condition that most clini-cians would accept. However, there is no evidence thatclinicians agree on the most important clinical diagnos-tic criteria.21 As a result, it is imperative that clinicalresearchers use established criteria for the diagnosis.22
For studies of treatment or outcome, electrodiagnostictests might also be required for study subjects, even ifthese would not normally be used in day-to-day clinicalpractice.
Another area in which the literature is deficient isthat of outcome measurement. There is widespreadvariation among researchers on what should be mea-sured in studies of treatment in CTS. The cardinalsymptom of the condition is a sensory disturbance inthe median nerve distribution, but this can be inter-preted by patients, and also by clinicians and research-ers, as “pain.” Although it is clear that this sensorydisturbance might not be comfortable, for purposes ofidentifying the cause of the symptoms and the effect onthis symptom of treatment, it is probably inappropriateto consider the symptom as synonymous with the painthat might be experienced after an injury such as a
fracture. However, this is how the outcome of treatmentarch
NONSURGICAL TREATMENT OF CARPAL TUNNEL SYNDROME 533
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in CTS is often reported. It is essential that the inves-tigators explicitly describe their outcome measure andthat it is valid, reliable, and meaningful. The method-ologists who specialize in measurement would call thislatter characteristic “sensibility.” What qualifies as sen-sibility varies with the research question, but it is a keyconsideration for interpreting the meaning of researchfindings. Outcomes such as a return to work activities,while of substantial and justifiable interest, often fail tomeet the necessary requirements of being valid andreliable, and even of being meaningful, because of themany confounding factors that can influence whether ornot an individual returns to work after treatment. Sim-ilarly, instruments that focus on disability, such as theDisabilities of the Arm, Shoulder, and Hand question-naire, are probably insufficiently responsive to be usefulfor studies of a condition such as CTS.
Finally, the natural history of CTS is unknown, al-though it appears clear that, at least in some individuals,the symptoms can vary through time. This is anotherimportant and potentially confounding factor to con-sider in evaluating the effects of treatment on the symp-toms attributed to this condition.
There is a need for natural history studies in CTS,including studies that evaluate the impact of activitymodification when it is has been assumed that exposureto certain work activities is associated with CTS. Theseare important studies that have not been undertakenusing a methodologically rigorous approach. It is en-tirely possible, perhaps even likely, that these studieswould show that activity modification is ineffective andthat many of the purported linkages between symptomsof CTS and work activity are spurious. These studieswill require careful case definition using diagnosticcriteria that are reliable, valid, and agreed upon by aconsensus of clinicians. Similarly, the outcome mea-sures that are used to evaluate the effects of interven-tions in CTS should be meaningful as well as valid andreliable. The Levine symptom severity scale23 meetsthese requirements and should be considered the stan-dard instrument for use in studies of CTS treatment anddisease activity.
CURRENT CONCEPTS
The literature indicates that nonsurgical treatment mightbe indicated for patients with a clear diagnosis of CTSwhen surgery is not desired or accessible or for anyother reason not immediately indicated. Splinting is abasic, easily implemented, inexpensive, and effectiveintervention. Steroid injection into the carpal tunnel is
also effective and, together with splinting, might beJHS �Vol A, M
superior to splinting alone. A short pulse of systemicsteroid treatment might also be effective, although therisk of long-term complication of even a short systemicexposure to steroid might not be fully known. In addi-tion, systemic steroid treatment, although superior toplacebo, is not as effective as local steroid injection.
My treatment for the individual described in this casewould be to institute nocturnal splinting for a period of6 weeks. If this were effective, then a period of gradualweaning from splinting would be recommended, with areturn to splinting as required over the next 6–12weeks. When splinting is ineffective or only partiallyeffective, the patient would be advised to consider hav-ing surgical decompression or, alternatively, continuingnonsurgical treatment with the addition of a steroidinjection into the carpal canal. Given the unknownlong-term effects of systemic steroid treatment, I do notrecommend this approach.
REFERENCES
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2. Garland H, Langworth EP, Taverner D, Clark JM. Surgical treatmentfor the carpal tunnel syndrome. Lancet 1964;1:1129–1130.
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