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

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Abstract
Non‐surgical treatment for carpal tunnel syndrome is frequently offered to those with mild to moderate symptoms. The effectiveness and duration of benefit from non‐surgical treatment for carpal tunnel syndrome remain unknown. To evaluate the effectiveness of non‐surgical treatment (other than steroid injection) for carpal tunnel syndrome versus a placebo or other non‐surgical, control interventions in improving clinical outcome. We searched the Cochrane Neuromuscular Disease Group specialised register (searched March 2002), MEDLINE (searched January 1966 to February 7 2001), EMBASE (searched January 1980 to March 2002), CINAHL (searched January 1983 to December 2001), AMED (searched 1984 to January 2002), Current Contents (January 1993 to March 2002), PEDro and reference lists of articles. Randomised or quasi‐randomised studies in any language of participants with the diagnosis of carpal tunnel syndrome who had not previously undergone surgical release. We considered all non‐surgical treatments apart from local steroid injection. The primary outcome measure was improvement in clinical symptoms after at least three months following the end of treatment. Three reviewers independently selected the trials to be included. Two reviewers independently extracted data. Studies were rated for their overall quality. Relative risks and weighted mean differences with 95% confidence intervals were calculated for the primary and secondary outcomes in each trial. Results of clinically and statistically homogeneous trials were pooled to provide estimates of the efficacy of non‐surgical treatments. Twenty‐one trials involving 884 people were included. A hand brace significantly improved symptoms after four weeks (weighted mean difference (WMD) ‐1.07; 95% confidence interval (CI) ‐1.29 to ‐0.85) and function (WMD ‐0.55; 95% CI ‐0.82 to ‐0.28). In an analysis of pooled data from two trials (63 participants) ultrasound treatment for two weeks was not significantly beneficial. However one trial showed significant symptom improvement after seven weeks of ultrasound (WMD ‐0.99; 95% CI ‐1.77 to ‐ 0.21) which was maintained at six months (WMD ‐1.86; 95% CI ‐2.67 to ‐1.05). Four trials involving 193 people examined various oral medications (steroids, diuretics, nonsteroidal anti‐inflammatory drugs) versus placebo. Compared to placebo, pooled data for two‐week oral steroid treatment demonstrated a significant improvement in symptoms (WMD ‐7.23; 95% CI ‐10.31 to ‐4.14). One trial also showed improvement after four weeks (WMD ‐10.8; 95% CI ‐15.26 to ‐6.34). Compared to placebo, diuretics or nonsteroidal anti‐inflammatory drugs did not demonstrate significant benefit. In two trials involving 50 people, vitamin B6 did not significantly improve overall symptoms. In one trial involving 51 people yoga significantly reduced pain after eight weeks (WMD ‐1.40; 95% CI ‐2.73 to ‐0.07) compared with wrist splinting. In one trial involving 21 people carpal bone mobilisation significantly improved symptoms after three weeks (WMD ‐1.43; 95% CI ‐2.19 to ‐0.67) compared to no treatment. In one trial involving 50 people with diabetes, steroid and insulin injections significantly improved symptoms over eight weeks compared with steroid and placebo injections. Two trials involving 105 people compared ergonomic keyboards versus control and demonstrated equivocal results for pain and function. Trials of magnet therapy, laser acupuncture, exercise or chiropractic care did not demonstrate symptom benefit when compared to placebo or control. Current evidence shows significant short‐term benefit from oral steroids, splinting, ultrasound, yoga and carpal bone mobilisation. Other non‐surgical treatments do not produce significant benefit. More trials are needed to compare treatments and ascertain the duration of benefit. Traitement non chirurgical (autre que l'injection de stéroïdes) dans le syndrome du canal carpien Un traitement non chirurgical est souvent proposé aux patients atteints de syndrome du canal carpien présentant des symptômes légers à modérés. À ce jour, l'efficacité du traitement non chirurgical du syndrome du canal carpien et la durée des effets bénéfiques ne sont pas établis. Évaluer l'efficacité du traitement non chirurgical (autre que l'injection de stéroïdes) dans le syndrome du canal carpien par rapport à un placebo ou à d'autres interventions non chirurgicales de contrôle pour améliorer les résultats cliniques. Nous avons consulté le registre spécialisé du groupe Cochrane sur les affections neuromusculaires (recherche effectuée en mars 2002), MEDLINE (de janvier 1966 au 7 février 2001), EMBASE (de janvier 1980 à mars 2002), CINAHL (de janvier 1983 à décembre 2001), AMED (de 1984 à janvier 2002), Current Contents (de janvier 1993 à mars 2002) et PEDro, ainsi que les références bibliographiques des articles. Les études randomisées ou quasi‐randomisées dans n'importe quelle langue portant sur des participants présentant un diagnostic de syndrome du canal carpien et n'ayant pas subi de libération chirurgicale préalable. Nous avons pris en compte tous les traitements non chirurgicaux à l'exception de l'injection locale de stéroïdes. Le critère de jugement principal était l'amélioration des symptômes cliniques au moins trois mois après la fin du traitement. Trois évaluateurs ont sélectionné les essais à inclure de manière indépendante. Deux relecteurs ont extrait des données de façon indépendante. 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