Carpal Tunnel Syndrome
Conventional treatment of CTS can be conservative (eg, medication, physical therapy, corticosteroid injections) or surgical. Generally, conservative treatment is preferred for patients with mild symptoms, while surgery is considered for patients with moderate to severe pain and disability (Ghasemi-Rad 2014). A systematic review of the literature found surgical treatment yielded better results at six and 12 months than conservative medical treatment. However, the authors concluded that given evidence for the success of conservative treatment and the risk of side effects and complications from surgery, surgery should be reserved for severe and refractory cases (ie, those that do not respond to other therapies) (Shi 2011).
Corticosteroids. Corticosteroids, typically injected but sometimes taken orally, may be used to treat CTS (Ashworth 2010; Chang 1998; Marshall 2007). Injectable corticosteroids, delivered into the carpal tunnel, appear to be somewhat more effective than oral corticosteroids for alleviation of CTS symptoms, especially in the shorter term (Wong 2001; Ashworth 2010; Marshall 2007). Patients with mild CTS on the basis of nerve conduction studies appear to attain a greater duration of benefit from corticosteroid injection compared to those with moderate or severe CTS (Visser 2012). However, a potential concern with injectable corticosteroid treatment is that it may mask continued median nerve damage (Ashworth 2010). As a surgeon commented in the British Medical Journal, “Local steroid injections do not reduce the pressure on the nerve in the long term; all they do is reduce inflammation temporarily—nerve compression almost always returns” (Wallace 2000).
Non-steroidal anti-inflammatory drugs. As inflammation contributes to CTS (Ozturk 2010), oral non-steroidal anti-inflammatory drugs (NSAIDs) are sometimes used as a conservative treatment, although evidence for their effectiveness is mixed. One study compared local steroid injection to NSAID treatment in 32 CTS patients using wrist splints. Subjects who received NSAIDs exhibited improvement in some nerve conduction parameters and in their capacity to perform some intricate hand movements, such as writing and ‘stacking checkers.’ The study authors concluded that NSAIDs may be an effective treatment option when combined with wrist splinting (Gurcay 2009). A placebo-controlled trial in 73 CTS patients compared a diuretic, 20 mg/day of the NSAID tenoxicam-SR (Mobiflex), and a corticosteroid; the investigators found no significant reduction in symptoms in the diuretic or NSAID group compared to placebo (Chang 1998).
Topical treatment options. A patch containing the painkiller lidocaine (Lidoderm) was studied for the treatment of CTS-related pain. In a randomized study, adults were treated with either 5% lidocaine patches (52 subjects) or oral doses of 500 mg of naproxen (Aleve) twice daily (48 subjects). After 6 weeks of treatment, significant reductions in pain were reported in both the lidocaine- and naproxen-treated groups, with no significant difference between the two groups (Nalamachu 2006). Another study reported that treatment with EMLA cream (containing lidocaine 2.5% plus prilocaine 2.5%) for four weeks resulted in a significant reduction in pain in 30 subjects with CTS (Moghtaderi 2009).
Surgery to relieve carpal tunnel pressure (called “carpal tunnel release”) is often used when conservative treatment fails and in severe cases. Surgery can be performed either through a standard open incision or using minimally invasive endoscopic instruments inserted through smaller incisions. Endoscopic surgery requires a 2 cm incision, shorter than traditional open CTS surgery.
Early studies comparing the two methods reported that both surgical techniques were similarly effective (Huisstede, Randsdrop 2010), though some more recent research has indicated that new endoscopic CTS surgery techniques may produce better results than traditional open CTS surgery. In one study, CTS symptoms six and 12 months after surgery were significantly improved in 60 subjects who underwent endoscopic surgery compared to 60 subjects who received standard open CTS surgery. The average time to return to work was 16.6 days in the endoscopic group compared to 25.4 days in the standard surgical group. In addition, scar healing was judged by patients to be significantly better in the endoscopic group compared to standard open surgery (Tarallo 2014). Attempts to develop sonographically-guided endoscopic surgical methods to further decrease trauma from surgery, by using a surgical incision of just 1 mm, have been reported (Rojo-Manaute 2013; de la Fuente 2013).
A rigorous review and analysis of the scientific literature compared endoscopic surgery to any other surgical treatment of CTS. The authors found no difference in relief of symptoms, return to functional status, or rate of major complications between the methodologies. Endoscopy, however, showed some superiority in terms of incidence of minor complications and improvement in grip strength, and resulted in a quicker return to work (Vasiliadis 2014).
Physical and Mechanical Treatment Modalities
A variety of physical and mechanical measures have demonstrated benefit for relief and rehabilitation from CTS, including splints and immobilization, home exercises (eg, stretching), massage, and certain types of manipulative and mobilization therapies (Kilot 2013; Kostopoulos 2004).
Splinting. Use of splints that hold the wrist in a neutral position are often recommended for CTS, but evidence in support of this approach is of low quality (Baker 2012; LeBlanc 2011; Page 2012). Splinting may be combined with other treatment modalities, such as stretching and acupuncture. One study of 40 patients recovering from CTS surgery found that splinting was of no benefit, and bulky dressings may be more comfortable, as effective, and less expensive for post-surgical recovery in CTS compared to splinting (Cebesoy 2007).
A study compared four weeks of splinting devices and stretching exercises in 124 adults with mild-to-moderate CTS. Researchers compared a conventional splint to a “lumbrical splint” and standard general hand and wrist stretching exercises to another set of stretching exercises designed to reduce tightness of the lumbrical muscles (muscles of the hand). Subjects received standard or lumbrical splints and instructions to perform either standard or lumbrical stretching exercises. After treatment, CTS symptoms improved significantly with all treatments; however, the best results were seen in subjects receiving standard splints combined with lumbrical stretching (Baker 2012).
Massage. Massage therapy has been the subject of several CTS trials. One trial that tested six weeks of twice-weekly massage and trigger-point therapy in 21 people with CTS reported significant improvement in symptom severity as well as functional ability of the hand and wrist (Elliot 2013). An earlier study compared six weeks of twice-weekly 30-minute sessions of general massage to carpal-tunnel-targeted massage. Targeted massage therapy resulted in a significant 17.3% increase in grip strength compared to a 4.8% increase in the general massage group (Moraska 2008). A randomized, controlled trial compared splinting plus self-massage to splinting alone. Both groups had six months of splinting, with the self-massage group self-treating for six weeks. Both grip strength and patient-physician assessment of CTS symptoms improved to a significantly greater extent in the subjects who underwent splinting and self-massage compared to those utilizing splinting alone (Madenci 2012).
Manipulation and mobilization techniques. When performed by a skilled practitioner, manual manipulation of the structures of and surrounding the carpal tunnel, including bones, tendons, ligaments, and muscles, may relieve CTS symptoms. Such treatments are meant to increase the volume of the carpal tunnel by increasing the length of the transverse carpal ligament, thus decreasing pressure on the median nerve (Schreiber 2014; Sucher 1998; Sucher 2012; Siu 2012). Some physical medicine practitioners report that mobilization of the involved nerve itself has produced symptomatic improvement (Kostopoulos 2004).
Transcutaneous Electrical Nerve Stimulation
Transcutaneous electrical nerve stimulation (TENS) involves passing low-intensity electrical current through the skin to stimulate nerves. It has been studied, with reported success, in a variety of medical pain management settings; however, further high quality controlled studies are necessary to conclusively demonstrate its efficacy (Sbruzzi 2012; Proctor 2002; Bennett 2011; Robb 2008; Osiri 2000). TENS treatment may reduce inflammation and stimulate ATP production (Branco 1999; Naeser 2002). (ATP is a critical cellular energy reservoir used throughout the body.) In a double-blind, placebo-controlled study, 11 subjects with borderline-mild or moderate CTS were treated with red-beam laser therapy, infrared laser therapy, and TENS or sham/placebo treatment three times weekly for 3-4 weeks in random sequence. After active treatment, signs and symptoms of CTS were significantly reduced compared to sham treatment (Naeser 2002). Another study on 31 subjects with CTS, some of whom had involvement of both hands, reported that 4-5 weeks of combined red-beam laser and TENS treatment resulted in significant reduction in wrist pain (Branco 1999).