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Treatment of carpal tunnel syndrome
Authors
Kevin R Scott, MD
Milind J Kothari, DO
Section Editor
Jeremy M Shefner, MD, PhD
Deputy Editor
John F Dashe, MD, PhD
Last literature review version 17.1: January 2009 | This topic last updated: October 3, 2007 (More)
INTRODUCTION — Carpal tunnel syndrome (CTS) is the most common compressive focal mononeuropathy seen in clinical practice. CTS refers to the symptom complex brought on by compression of the median nerve as it travels through the carpal tunnel. Patients commonly experience pain, paresthesias, and less commonly, weakness in the median nerve distribution.
This topic review will discuss treatment of CTS. We will also briefly review the etiology, clinical features, and diagnosis of CTS, which are discussed in greater detail separately. (See "Etiology of carpal tunnel syndrome" and see "Clinical manifestations and diagnosis of carpal tunnel syndrome").
BACKGROUND — The carpal tunnel is formed by the transverse carpal ligament superiorly with the carpal bones inferiorly (show figure 1) [1]. It is through this anatomic tunnel that the median nerve travels, accompanied by the nine flexor tendons of the forearm musculature (show figure 2) [1-3].
When compression of the nerve occurs, ischemia and mechanical disruption of nerve function may result. Compression induces dysfunctional axonal transport and epidural blood flow due to increased carpal tunnel pressure (CTP) [2]. Pathological analysis shows edema and thickening of vessel walls within the endoneurium and perineurium, fibrosis, myelin thinning, and nerve fiber degeneration and regeneration [2,4,5].
Upper extremity posture influences CTS by altering CTP. The lowest CTP is seen in a neutral or slightly flexed position, and it increases proportionately with deviation from this posture [2,6-9]. The incidence of CTS is increased in individuals with underlying nerve dysfunction (eg, hereditary neuropathies), diabetes, hypothyroidism, connective tissue diseases, obesity, and pregnancy. (See "Etiology of carpal tunnel syndrome").
The median nerve has a sensory distribution involving the volar surface of the first three fingers and lateral half of the fourth finger of the hand. Proximal to the wrist, the palmar sensory cutaneous nerve arises and supplies the region overlying the thenar eminence. This results in a distinctive clinical pattern of sensory loss over the median-innervated fingers with normal sensation over the thenar eminence.
The median nerve, and its anterior interosseous division, innervates several muscles of the forearm that mediate wrist and finger flexion. After passing through the carpal tunnel, the median nerve supplies the first and second lumbricals, opponens pollicis, abductor pollicis brevis, and flexor pollicis brevis muscles. Clinical signs may include weakness of thumb abduction with wasting of the thenar eminence.
Diagnosis — Carpal tunnel syndrome (CTS) is a clinical diagnosis. Pain or paresthesias of the hands are almost always present. CTS is often characterized by periods of remission and exacerbation [10]. Most commonly, symptoms are limited to the median-innervated fingers; however, some patients report involvement of the entire hand. It is not uncommon for sensory symptoms to radiate proximally into the forearm, and less frequently radiate proximal to the elbow.
Symptoms of CTS are often reported to be worse at night and may be severe enough to awaken patients. Patients may need to "shake out" their hands or run them under warm water. Symptoms are often provoked by activities requiring prolonged wrist flexion/extension such as driving, reading, typing, and holding a telephone.
Sensory deficits are seen involving the median-innervated fingers, but sparing the thenar eminence. This is a critical finding, as sensory loss over the thenar eminence suggests a more proximal lesion. Weakness is limited to muscles of the thenar eminence. This manifests principally as weakness of thumb abduction. Depending on the severity, atrophy of the thenar eminence can be seen.
Provocative maneuvers such as Phalen's test, Tinel's sign, and manual carpal compression testing (mCCT) can be helpful when interpreted in the proper clinical context.
* Phalen's sign is defined as pain and/or paresthesias in the median-innervated fingers with one minute of wrist flexion. Meta-analyses have shown an average sensitivity of 68 percent and specificity of 73 percent for a "positive" Phalen's test [11]. Only Phalen's test has been shown to correlate with CTS severity when studied prospectively [12].
* Tinel's sign (pain and/or paresthesias of the median-innervated fingers with percussion over the median nerve) is less sensitive (50 percent), but slightly more specific (77 percent) than Phalen's sign [11].
* Manual carpal compression testing involves applying pressure over the transverse carpal ligament, and it is deemed "positive" if paresthesias occur within 30 seconds of applying pressure. The average sensitivity of mCCT is 64 percent with an average specificity of 83 percent [11].
Nerve conduction studies (NCS) are a sensitive measure of detecting compression of the median nerve as it travels through the carpal tunnel. The electrodiagnosis rests upon demonstrating impaired median nerve conduction across the carpal tunnel in the context of normal conduction elsewhere [1,3]. Compression results in damage to the myelin sheath and manifests as delayed distal latencies and slowed conduction velocities. If myelin damage is severe enough, secondary axonal loss may occur, manifesting as reduced median nerve compound muscle action potential amplitude.
Natural history — The natural history of CTS is not well defined. One study of nearly 200 patients with CTS, which included baseline and follow-up data on symptoms and neurophysiologic parameters, reported that the symptoms of untreated patients with minimal or mild compression tended to worsen over 10 to 15 months, while those with initially moderate or severe involvement tended to improve [13]. Among the factors that predicted progression were a positive Phalen test and bilateral disease.
Global symptom score (GSS) — The global symptom score is a patient rating of symptom severity that is often used as a research tool to assess efficacy of treatment in clinical studies [14,15].
Using a standardized symptom questionnaire, patients rate five categories of symptoms (pain, numbness, paresthesias, weakness/clumsiness, and nocturnal awakening) on a scale from 0 (no symptoms) to 10 (severe symptoms) [15]. The sum of the scores in each of the five categories is termed the global symptom score (GSS), which ranges from 0 (no symptoms) to 50 (worst symptoms).
TREATMENT — Many options are available for the treatment of patients with carpal tunnel syndrome (CTS) and the modality chosen depends on the severity of nerve dysfunction (ie, mild, moderate, or severe). The specific choice of therapy will also vary according to patient preference and availability.
For patients with mild to moderate CTS, conservative therapy is generally considered to be a reasonable first option with successful outcomes ranging from 20 to 93 percent [16,17]. Conservative options include splinting, oral corticosteroids or injections, ultrasound, nerve-gliding exercises, and yoga. Combined therapy may be more effective than the use of any single modality [10,16,18-20].
Predictors associated with failure of conservative therapy include the following features [16,17,21]:
* Long duration of symptoms (>10 months)
* Age greater than 50
* Constant paresthesias
* Impaired two-point discrimination (>6 mm)
* Positive Phalen's sign <30 seconds
* Prolonged motor and sensory latencies demonstrated by electrodiagnostic testing
A variety of patient factors including heredity, size of the carpal tunnel, associated local and systemic diseases, and habits may contribute to the etiology of CTS. Evaluation and treatment of potential predisposing conditions, including obesity, diabetes, rheumatoid arthritis, other connective tissue diseases, and thyroid disease, is warranted in patients with CTS, although there is no proof that treating these conditions will improve the symptoms or the course of CTS. (See "Etiology of carpal tunnel syndrome" and see "Neurologic manifestations of hypothyroidism", section on Carpal tunnel syndrome).
Wrist splinting — A wrist splint or brace maintains the wrist in a neutral position, thus preventing prolonged flexion or extension of the wrist. Splinting may limit activities that raise pressure within the carpal tunnel or reduce its cross sectional area.
Splinting is generally thought to be effective in reducing CTS symptoms, and it may delay or eliminate the need for surgery in mildly symptomatic patients [16,18,20,22,23]. A 2003 systematic [20] review found only one randomized trial [24] that evaluated nocturnal wrist splinting versus no treatment. Based on this limited evidence, the review concluded that nocturnal use of wrist splints was associated with significant benefit for symptoms and hand function at four weeks [20].
Clinical features that favor a long-term clinical response to splinting are shorter duration of symptoms (one year or less) and less severe nocturnal paresthesias [25]. Similarly, when splinting and steroid injections (see "Corticosteroid injection" below) are combined, symptom duration of less than three months, and absence of sensory impairment at presentation, may be predictive of a lasting response to conservative treatment [26].
Splints are usually worn at night, but they can be worn continuously. Night splinting alone can reduce symptom severity and improve median nerve conduction velocities [10,24,27]. Full-time splinting has been reported to improve median nerve conduction, but it may not improve symptoms when compared with night-only splinting [10,23].
Splints can be purchased over the counter (OTC) or be custom made by an occupational therapist with subspecialty certification in hand therapy (CHT). There are no studies comparing treatment outcomes with custom splints versus OTC models.
Splinting versus surgery — Surgical treatment of CTS appears to be more effective than splinting, although the evidence is limited to a few relatively low-quality trials. A 2003 systematic review [28] found only two randomized trials [22,29] that compared splinting with surgery and neither trial employed blinded assessment of outcomes.
In one trial, 176 patients with CTS, documented by nerve conduction studies, were randomly assigned to either nocturnal wrist splinting or surgical decompression [22]. There was less rapid, but more complete and longer lasting relief of symptoms with surgery than splinting. At one month, complete or marked improvement was seen in 29 percent treated with surgery versus 42 percent treated with splinting. However, at one year, complete or marked improvement was seen in 92 percent treated with surgery versus 72 percent treated with splinting. In the systematic review of this trial, significantly more patients experienced clinical improvement at three months with surgery than with splinting (71 versus 51.6 percent) with a relative risk (RR) for clinical improvement favoring surgery of 1.38 (95% CI 1.08-1.75) [28].
Pooled data for clinical improvement at one year also favored surgery (RR 1.27; 95% CI 1.05-1.53) [28]. In addition, pooled data regarding the need for surgery in the splinting group or reoperation in the surgery group during follow-up favored surgery (RR 0.04, 95% CI 0.01-0.17).
Corticosteroid injection — Injection of corticosteroids into the region of the carpal tunnel is intended to reduce tissue inflammation and aid recovery. Its value relative to conservative treatment (eg, splinting) has been controversial [30,31] because no well-controlled comparative studies have been performed, and because a prominent histological inflammatory response is not usually seen with CTS [2,32-35].
Corticosteroids can be injected proximal or distal to the carpal tunnel. Injections appear to be safe; although cases of median nerve injury [36] after injections have been reported.
In general, corticosteroid injections appear effective in reducing subjective symptoms of CTS for one to three months when compared with placebo [27,37,38]. The clinical impression that corticosteroid injection provides short-term symptomatic relief is supported by the following observations:
* A 2007 systematic review evaluated 12 trials, including two high-quality randomized controlled trials, and concluded that corticosteroid injections provided greater symptom improvement at one month than placebo, but relief beyond one month was not established [39].
* A controlled trial randomly assigned 81 patients with nerve conduction study proven CTS refractory to splinting to injection with glucocorticoid (betamethasone 6 mg in 1 mL and 1 mL of 1 percent lidocaine) or sham (saline plus lidocaine) [40]. At two weeks following the initial injection, significantly more of the glucocorticoid-injected than sham-injected patients were 'somewhat or highly satisfied' (70 versus 34 percent, respectively). When nonresponders to sham injection subsequently received a betamethasone injection, the proportion reporting improvement was 73 percent.
In an uncontrolled extension of this trial, only 4 of 46 patients (9 percent) whose CTS symptoms improved following an initial injection had good symptomatic control for up to 18 months [40]. Additional injections (two to seven) controlled symptoms in 13 others (28 percent); surgical referral was requested by 18 patients (43 percent).
* A prospective blinded study looked at 120 patients who were randomly assigned to steroid injections either proximal (4 cm proximal to the wrist crease and between the flexor tendons) or distal (at the anterior wrist crease just medial to the palmaris longus tendon) to the carpal tunnel, and compared with conservative therapy. This study used a mixture containing 3 mg betamethasone disodium phosphate, 3 mg betamethasone acetate, and 0.5 cc of 2 percent lidocaine HCL. A significant improvement in Global Symptom Score (GSS) was reported for up to 12 weeks when compared with placebo [27].
An earlier, similar study using 15 mg of methylprednisolone acetate injected into the carpal tunnel of 30 patients also resulted in improvement in the GSS for up to 12 weeks relative compared with low-dose short-term oral prednisolone [41].
Injection therapy is associated with several risks, including exacerbation of median nerve compression, accidental injection into the median or ulnar nerves, and digital flexor tendon rupture [31,42].
Corticosteroid injection versus surgery — Surgery appears to be more effective for sustained relief of symptoms from CTS than local corticosteroid injection. While short-term results of corticosteroid injection may be better than those following carpal tunnel release surgery, the advantage is lost over the course of one year following the procedure. These points are illustrated by the following studies:
* One prospective, open study randomly assigned 163 patients with symptomatic CTS to glucocorticoid injection into the carpal tunnel (20 mg of paramethasone acetonide) or surgical release (via a limited palmar incision) [43]. The main outcome was the proportion of patients in each group who had at least 20 percent improvement in nocturnal paresthesias. Significantly more of those who were assigned to injection than surgery were improved at three months (approximately 95 versus 75 percent, respectively). Over the ensuing nine months of observation, the advantage of injection over surgery was lost, while those treated surgically generally maintained the degree of improvement noted at the three-month point.
The patients in this study were predominantly Spanish housewives, and compensation for disability due to CTS was rarely an issue. Thus, the applicability of these results to patients with work-related CTS is uncertain.
* A subsequent assessor-blinded controlled trial randomly assigned 50 patients (48 were female) with CTS to a single injection of methylprednisolone 15 mg or open surgical carpal tunnel decompression [44]. At 20 weeks, surgical treatment was associated with significantly greater symptomatic improvement in the GSS score, the primary outcome, than local steroid injection (24.2 versus 8.7, respectively). The dose of methylprednisolone (15 mg) used in the trial is much less than the 40 mg most commonly used in practice.
Oral steroids — Oral corticosteroids appear to be effective for short-term improvement of CTS symptoms. In a 2003 systematic review, analysis of pooled data from three trials of high and moderate methodologic quality showed that two weeks of oral steroid treatment was associated with a statistically significant reduction in symptoms as measured by the GSS compared with placebo (weighted mean difference [WMD] -7.23; 95% CI -10.31 to -4.14); one trial showed that four weeks of oral steroid treatment was associated with a statistically significant reduction in symptoms (WMD -10.8; 95% CI -15.26 to -6.34) [20].
There are only limited data regarding the long-term effect of oral steroids for CTS treatment. In one clinical trial that evaluated two to four weeks of treatment with up to 20 mg per day of oral prednisolone, patients showed clinical and electrodiagnostic improvement for up to 12 months [45]. However, this study did not have a placebo control group. In another clinical trial, patients treated with oral prednisolone 25 mg daily for 10 days showed symptomatic improvement in CTS for up to eight weeks [41]. However, oral prednisolone was less effective than corticosteroid injection. In a placebo-controlled trial that evaluated patients with mild to moderate CTS, two weeks of oral prednisone (20 mg daily for seven days, followed by 10 mg per day for seven days) was associated with significant improvement in symptoms as measured by the GSS, but the benefit gradually waned over eight weeks of observation [14].
Yoga — Limited evidence suggests that yoga may be beneficial for pain control in patients with CTS. A preliminary assessor-blinded controlled trial randomly assigned 42 patients with CTS to eight weeks of treatment with yoga or wrist splinting. The yoga intervention consisted of 11 yoga postures designed for strengthening, stretching, and balancing each joint in the upper body along with relaxation given twice weekly [46]. Patients in the yoga group had statistically significant pain reduction compared with patients in the wrist splint group.
Carpal bone mobilization — Carpal bone mobilization is a physical and occupational therapy technique that involves movement of the bones and joints in the wrist. Data are limited, but a small trial involving 21 people found that carpal bone mobilization significantly improved symptoms (assessed using a symptom diary with a visual analog scale) after three weeks compared with no treatment (WMD -1.43; 95% CI -2.19 to -0.67) [20,47]. However, there was no significant benefit in short-term pain or hand function.
Nerve gliding — Nerve and tendon gliding exercises or maneuvers are performed under the direction of an occupational therapist with subspecialty certification in hand therapy (CHT). Nerve gliding is predicated on restoring normal movement of the median nerve. It is thought that nerve compression may lead to "tethering" of the median nerve, resulting in decreased nerve excursion and increased mechanical strain [2]. Reduced sliding of the median nerve in the transverse [16,48,49] and longitudinal [16,50] planes has been observed in CTS patients [2,16].
Data regarding nerve gliding are limited to a few small studies with equivocal results. Nerve gliding exercises alone were reported to decrease pain and increase range of motion in one study [47]. Other studies have suggested that nerve gliding in combination with splinting may allow surgery to be avoided [19] and improve patient satisfaction [16,19]. However, a prospective, randomized, unblinded trial involving 36 patients found that nerve and tendon gliding exercises for four weeks provided no statistically significant benefit at eight weeks compared with wrist splinting for symptom improvement or patient satisfaction [18].
Ultrasound therapy — Ultrasound and electrical stimulation have been used to promote recovery after nerve and tendon injuries [51]. Ultrasound is used to promote soft tissue healing and the transdermal delivery of medications at intensities ranging from 0.5 to 1.5 w/cm2. At its lower intensity range, ultrasound induces changes in cell permeability, termed "microstreaming", that are thought to enhance the healing response. At its upper range, ultrasound raises tissue temperature while reducing pain, increases tissue elasticity, and decreases tissue viscosity [51].
Data regarding the benefit of ultrasound for CTS are conflicting, although its effectiveness may depend on the duration of therapy. A 2003 systematic review, analyzing pooled data from two trials with 63 participants, found that ultrasound treatment for two weeks was not significantly beneficial [20]. However, one trial showed that ultrasound treatment for seven weeks was associated with significant symptom improvement (WMD -0.99; 95% CI -1.77 to -0.21), and the benefit was maintained at six months (WMD -1.86; 95% CI -2.67 to -1.05).
The effectiveness of ultrasound may depend on the characteristics of the ultrasound used [10,20]. Deep, pulsed ultrasound has been reported to decrease pain and improve sensory loss, nerve conduction parameters, and strength [10,52]. Continuous superficial ultrasound does not improve patients' symptoms or median nerve conduction parameters [10,53].
NSAIDS and other oral medications — A 2003 systematic review [20] found one randomized controlled trial [15] that demonstrated no significant benefit for nonsteroidal anti-inflammatory drugs (NSAIDS) when compared with placebo for improving CTS symptoms.
The available data suggest no benefit for diuretics [15,20] or vitamin B6 [20] for improving CTS symptoms.
Electrical, magnetic, and laser therapy — No clear hypotheses have been generated to support the use of any of these modalities for the treatment of CTS.
Only anecdotal evidence exists regarding electrical stimulation for the treatment of CTS. A single session of magnetic therapy was not effective when compared with sham therapy [10,54], and prolonged magnetic therapy was not effective compared with placebo [10,20,55]. Similarly, low-level laser therapy has not been proven in a controlled study design [10,20,56].
Conservative treatment choices — For patients with mild to moderate symptomatic CTS, we recommend nocturnal wrist splinting as preferred initial medical therapy because limited evidence suggests it is effective for short-term symptom relief. It is also safe and well-tolerated. (See "Wrist splinting" above).
Although evidence is limited, combined treatment employing splinting in combination with corticosteroid injection(s), oral steroids, or other conservative interventions may provide additional symptomatic relief and avoid the need for surgical decompression. (See "Treatment" above).
For patients with mild to moderate symptomatic CTS who do not tolerate or respond to splinting, we suggest treatment with corticosteroid injection or oral corticosteroid treatment. Oral steroid treatment should not extend beyond four weeks duration because of the deleterious side effects of prolonged corticosteroid therapy. (See "Corticosteroid injection" above and see "Oral steroids" above).
Limited data suggest that yoga and carpal bone mobilization may be reasonable alternative options for conservative treatment if available. (See "Yoga" above and see "Carpal bone mobilization" above).
Pregnancy — CTS may develop during pregnancy, particularly during the third trimester. In most cases, the symptoms gradually resolve over a period of weeks after delivery. For women who develop CTS during pregnancy, we recommend nocturnal wrist splinting. Surgical decompression is rarely indicated during pregnancy since the disease often resolves postpartum. (See "Neurologic disorders complicating pregnancy", section on Carpal tunnel syndrome).
Surgery — Surgical decompression is effective treatment for CTS, as evidenced by improved subjective and objective long-term measures [22,28,57,58]. (See "Splinting versus surgery" above and see "Corticosteroid injection versus surgery" above).
Additional data supporting this conclusion come from a study that systematically reviewed 209 articles published from 2000 to 2006 with patient-reported outcomes for 32,936 operations for CTS [59]. Surgery was considered successful for the outcomes of "cure", "much better", "80 percent improvement", and "satisfactory". Although there was wide variation in success rates among individual studies (range, 27 to 100 percent), the pooled success rate of surgery was 75 percent.
For patients with moderate to severe persistent CTS symptoms (eg, numbness and pain, diminished hand function, or thenar eminence atrophy), particularly those with long duration of symptoms (greater than six months) and confirmatory electrodiagnostic evidence of median nerve injury, we suggest surgical decompression. Surgery prior to six months may be reasonable for patients who do not improve despite adequate trials of conservative therapy, or whose symptoms recur after initial improvement with conservative therapy.
Surgery for CTS is discussed in greater detail separately. (See "Surgery for carpal tunnel syndrome").
SUMMARY AND RECOMMENDATIONS — For patients with mild to moderate carpal tunnel syndrome (CTS), effective conservative treatment options for short-term improvement include splinting, corticosteroids injected into the carpal tunnel, and oral corticosteroids. Carpal bone mobilization and yoga may also be beneficial. Combined therapy may be more effective than the use of any single modality. Referral to an occupational therapist with subspecialty certification in hand therapy (CHT) may improve outcomes. (See "Treatment" above).
* Unproven CTS treatments include nerve-gliding maneuvers, ultrasound, electrical stimulation, low-level laser therapy, magnetic therapy, contrast baths, and myofascial massage. Ineffective CTS treatments include nonsteroidal antiinflammatory medications (NSAIDS), vitamin B6, and diuretics. (See "Treatment" above).
* Clinical features associated with failure of conservative CTS therapy include duration of symptoms >10 months, age >50, constant paresthesias, impaired two-point discrimination (>6 mm), positive Phalen's sign <30 seconds, and prolonged motor and sensory latencies. (See "Treatment" above).
* For untreated patients with mild to moderate symptomatic CTS of ≤10 months duration, we recommend nocturnal wrist splinting in the neutral position as initial therapy in preference to other conservative measures (Grade 1B). (See "Wrist splinting" above).
* For patients who comply with nocturnal splinting, but remain symptomatic at one month, we suggest continuation of splinting for another one to two months while adding a different conservative modality as discussed below, rather than stopping splinting (Grade 2C). (See "Treatment" above).
* For patients with CTS with an inadequate response to wrist splinting, we suggest a single injection with methylprednisolone (40 mg) as the next therapeutic option rather than oral steroids (Grade 2B). For patients who decline injection therapy, we suggest treatment with oral corticosteroids (Grade 2B). We use prednisone 20 mg daily for 10 to 14 days. (See "Corticosteroid injection" above and see "Oral steroids" above).
* For patients with mild to moderate CTS who decline treatment with corticosteroids, we suggest treatment with other conservative measures including carpal bone mobilization or yoga (Grade 2C). (See "Carpal bone mobilization" above and see "Yoga" above.
* We recommend NOT using nonsteroidal antiinflammatory medication for the treatment of CTS (Grade 1B). (See "NSAIDS and other oral medications" above).
* Surgery appears to be more effective than splinting or corticosteroid injection for sustained CTS symptom relief. For patients with moderate to severe CTS that is refractory to conservative measures, we suggest surgical decompression (Grade 2B). (See "Splinting versus surgery" above, see "Corticosteroid injection versus surgery" above and see "Surgery for carpal tunnel syndrome").
ACKNOWLEDGMENT — The authors and editorial staff at UpToDate would like to acknowledge Robert P Sheon, MD, who contributed to an earlier version of this topic review.
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Treatment of carpal tunnel syndrome
Authors
Kevin R Scott, MD
Milind J Kothari, DO
Section Editor
Jeremy M Shefner, MD, PhD
Deputy Editor
John F Dashe, MD, PhD
Last literature review version 17.1: January 2009 | This topic last updated: October 3, 2007 (More)
INTRODUCTION — Carpal tunnel syndrome (CTS) is the most common compressive focal mononeuropathy seen in clinical practice. CTS refers to the symptom complex brought on by compression of the median nerve as it travels through the carpal tunnel. Patients commonly experience pain, paresthesias, and less commonly, weakness in the median nerve distribution.
This topic review will discuss treatment of CTS. We will also briefly review the etiology, clinical features, and diagnosis of CTS, which are discussed in greater detail separately. (See "Etiology of carpal tunnel syndrome" and see "Clinical manifestations and diagnosis of carpal tunnel syndrome").
BACKGROUND — The carpal tunnel is formed by the transverse carpal ligament superiorly with the carpal bones inferiorly (show figure 1) [1]. It is through this anatomic tunnel that the median nerve travels, accompanied by the nine flexor tendons of the forearm musculature (show figure 2) [1-3].
When compression of the nerve occurs, ischemia and mechanical disruption of nerve function may result. Compression induces dysfunctional axonal transport and epidural blood flow due to increased carpal tunnel pressure (CTP) [2]. Pathological analysis shows edema and thickening of vessel walls within the endoneurium and perineurium, fibrosis, myelin thinning, and nerve fiber degeneration and regeneration [2,4,5].
Upper extremity posture influences CTS by altering CTP. The lowest CTP is seen in a neutral or slightly flexed position, and it increases proportionately with deviation from this posture [2,6-9]. The incidence of CTS is increased in individuals with underlying nerve dysfunction (eg, hereditary neuropathies), diabetes, hypothyroidism, connective tissue diseases, obesity, and pregnancy. (See "Etiology of carpal tunnel syndrome").
The median nerve has a sensory distribution involving the volar surface of the first three fingers and lateral half of the fourth finger of the hand. Proximal to the wrist, the palmar sensory cutaneous nerve arises and supplies the region overlying the thenar eminence. This results in a distinctive clinical pattern of sensory loss over the median-innervated fingers with normal sensation over the thenar eminence.
The median nerve, and its anterior interosseous division, innervates several muscles of the forearm that mediate wrist and finger flexion. After passing through the carpal tunnel, the median nerve supplies the first and second lumbricals, opponens pollicis, abductor pollicis brevis, and flexor pollicis brevis muscles. Clinical signs may include weakness of thumb abduction with wasting of the thenar eminence.
Diagnosis — Carpal tunnel syndrome (CTS) is a clinical diagnosis. Pain or paresthesias of the hands are almost always present. CTS is often characterized by periods of remission and exacerbation [10]. Most commonly, symptoms are limited to the median-innervated fingers; however, some patients report involvement of the entire hand. It is not uncommon for sensory symptoms to radiate proximally into the forearm, and less frequently radiate proximal to the elbow.
Symptoms of CTS are often reported to be worse at night and may be severe enough to awaken patients. Patients may need to "shake out" their hands or run them under warm water. Symptoms are often provoked by activities requiring prolonged wrist flexion/extension such as driving, reading, typing, and holding a telephone.
Sensory deficits are seen involving the median-innervated fingers, but sparing the thenar eminence. This is a critical finding, as sensory loss over the thenar eminence suggests a more proximal lesion. Weakness is limited to muscles of the thenar eminence. This manifests principally as weakness of thumb abduction. Depending on the severity, atrophy of the thenar eminence can be seen.
Provocative maneuvers such as Phalen's test, Tinel's sign, and manual carpal compression testing (mCCT) can be helpful when interpreted in the proper clinical context.
* Phalen's sign is defined as pain and/or paresthesias in the median-innervated fingers with one minute of wrist flexion. Meta-analyses have shown an average sensitivity of 68 percent and specificity of 73 percent for a "positive" Phalen's test [11]. Only Phalen's test has been shown to correlate with CTS severity when studied prospectively [12].
* Tinel's sign (pain and/or paresthesias of the median-innervated fingers with percussion over the median nerve) is less sensitive (50 percent), but slightly more specific (77 percent) than Phalen's sign [11].
* Manual carpal compression testing involves applying pressure over the transverse carpal ligament, and it is deemed "positive" if paresthesias occur within 30 seconds of applying pressure. The average sensitivity of mCCT is 64 percent with an average specificity of 83 percent [11].
Nerve conduction studies (NCS) are a sensitive measure of detecting compression of the median nerve as it travels through the carpal tunnel. The electrodiagnosis rests upon demonstrating impaired median nerve conduction across the carpal tunnel in the context of normal conduction elsewhere [1,3]. Compression results in damage to the myelin sheath and manifests as delayed distal latencies and slowed conduction velocities. If myelin damage is severe enough, secondary axonal loss may occur, manifesting as reduced median nerve compound muscle action potential amplitude.
Natural history — The natural history of CTS is not well defined. One study of nearly 200 patients with CTS, which included baseline and follow-up data on symptoms and neurophysiologic parameters, reported that the symptoms of untreated patients with minimal or mild compression tended to worsen over 10 to 15 months, while those with initially moderate or severe involvement tended to improve [13]. Among the factors that predicted progression were a positive Phalen test and bilateral disease.
Global symptom score (GSS) — The global symptom score is a patient rating of symptom severity that is often used as a research tool to assess efficacy of treatment in clinical studies [14,15].
Using a standardized symptom questionnaire, patients rate five categories of symptoms (pain, numbness, paresthesias, weakness/clumsiness, and nocturnal awakening) on a scale from 0 (no symptoms) to 10 (severe symptoms) [15]. The sum of the scores in each of the five categories is termed the global symptom score (GSS), which ranges from 0 (no symptoms) to 50 (worst symptoms).
TREATMENT — Many options are available for the treatment of patients with carpal tunnel syndrome (CTS) and the modality chosen depends on the severity of nerve dysfunction (ie, mild, moderate, or severe). The specific choice of therapy will also vary according to patient preference and availability.
For patients with mild to moderate CTS, conservative therapy is generally considered to be a reasonable first option with successful outcomes ranging from 20 to 93 percent [16,17]. Conservative options include splinting, oral corticosteroids or injections, ultrasound, nerve-gliding exercises, and yoga. Combined therapy may be more effective than the use of any single modality [10,16,18-20].
Predictors associated with failure of conservative therapy include the following features [16,17,21]:
* Long duration of symptoms (>10 months)
* Age greater than 50
* Constant paresthesias
* Impaired two-point discrimination (>6 mm)
* Positive Phalen's sign <30 seconds
* Prolonged motor and sensory latencies demonstrated by electrodiagnostic testing
A variety of patient factors including heredity, size of the carpal tunnel, associated local and systemic diseases, and habits may contribute to the etiology of CTS. Evaluation and treatment of potential predisposing conditions, including obesity, diabetes, rheumatoid arthritis, other connective tissue diseases, and thyroid disease, is warranted in patients with CTS, although there is no proof that treating these conditions will improve the symptoms or the course of CTS. (See "Etiology of carpal tunnel syndrome" and see "Neurologic manifestations of hypothyroidism", section on Carpal tunnel syndrome).
Wrist splinting — A wrist splint or brace maintains the wrist in a neutral position, thus preventing prolonged flexion or extension of the wrist. Splinting may limit activities that raise pressure within the carpal tunnel or reduce its cross sectional area.
Splinting is generally thought to be effective in reducing CTS symptoms, and it may delay or eliminate the need for surgery in mildly symptomatic patients [16,18,20,22,23]. A 2003 systematic [20] review found only one randomized trial [24] that evaluated nocturnal wrist splinting versus no treatment. Based on this limited evidence, the review concluded that nocturnal use of wrist splints was associated with significant benefit for symptoms and hand function at four weeks [20].
Clinical features that favor a long-term clinical response to splinting are shorter duration of symptoms (one year or less) and less severe nocturnal paresthesias [25]. Similarly, when splinting and steroid injections (see "Corticosteroid injection" below) are combined, symptom duration of less than three months, and absence of sensory impairment at presentation, may be predictive of a lasting response to conservative treatment [26].
Splints are usually worn at night, but they can be worn continuously. Night splinting alone can reduce symptom severity and improve median nerve conduction velocities [10,24,27]. Full-time splinting has been reported to improve median nerve conduction, but it may not improve symptoms when compared with night-only splinting [10,23].
Splints can be purchased over the counter (OTC) or be custom made by an occupational therapist with subspecialty certification in hand therapy (CHT). There are no studies comparing treatment outcomes with custom splints versus OTC models.
Splinting versus surgery — Surgical treatment of CTS appears to be more effective than splinting, although the evidence is limited to a few relatively low-quality trials. A 2003 systematic review [28] found only two randomized trials [22,29] that compared splinting with surgery and neither trial employed blinded assessment of outcomes.
In one trial, 176 patients with CTS, documented by nerve conduction studies, were randomly assigned to either nocturnal wrist splinting or surgical decompression [22]. There was less rapid, but more complete and longer lasting relief of symptoms with surgery than splinting. At one month, complete or marked improvement was seen in 29 percent treated with surgery versus 42 percent treated with splinting. However, at one year, complete or marked improvement was seen in 92 percent treated with surgery versus 72 percent treated with splinting. In the systematic review of this trial, significantly more patients experienced clinical improvement at three months with surgery than with splinting (71 versus 51.6 percent) with a relative risk (RR) for clinical improvement favoring surgery of 1.38 (95% CI 1.08-1.75) [28].
Pooled data for clinical improvement at one year also favored surgery (RR 1.27; 95% CI 1.05-1.53) [28]. In addition, pooled data regarding the need for surgery in the splinting group or reoperation in the surgery group during follow-up favored surgery (RR 0.04, 95% CI 0.01-0.17).
Corticosteroid injection — Injection of corticosteroids into the region of the carpal tunnel is intended to reduce tissue inflammation and aid recovery. Its value relative to conservative treatment (eg, splinting) has been controversial [30,31] because no well-controlled comparative studies have been performed, and because a prominent histological inflammatory response is not usually seen with CTS [2,32-35].
Corticosteroids can be injected proximal or distal to the carpal tunnel. Injections appear to be safe; although cases of median nerve injury [36] after injections have been reported.
In general, corticosteroid injections appear effective in reducing subjective symptoms of CTS for one to three months when compared with placebo [27,37,38]. The clinical impression that corticosteroid injection provides short-term symptomatic relief is supported by the following observations:
* A 2007 systematic review evaluated 12 trials, including two high-quality randomized controlled trials, and concluded that corticosteroid injections provided greater symptom improvement at one month than placebo, but relief beyond one month was not established [39].
* A controlled trial randomly assigned 81 patients with nerve conduction study proven CTS refractory to splinting to injection with glucocorticoid (betamethasone 6 mg in 1 mL and 1 mL of 1 percent lidocaine) or sham (saline plus lidocaine) [40]. At two weeks following the initial injection, significantly more of the glucocorticoid-injected than sham-injected patients were 'somewhat or highly satisfied' (70 versus 34 percent, respectively). When nonresponders to sham injection subsequently received a betamethasone injection, the proportion reporting improvement was 73 percent.
In an uncontrolled extension of this trial, only 4 of 46 patients (9 percent) whose CTS symptoms improved following an initial injection had good symptomatic control for up to 18 months [40]. Additional injections (two to seven) controlled symptoms in 13 others (28 percent); surgical referral was requested by 18 patients (43 percent).
* A prospective blinded study looked at 120 patients who were randomly assigned to steroid injections either proximal (4 cm proximal to the wrist crease and between the flexor tendons) or distal (at the anterior wrist crease just medial to the palmaris longus tendon) to the carpal tunnel, and compared with conservative therapy. This study used a mixture containing 3 mg betamethasone disodium phosphate, 3 mg betamethasone acetate, and 0.5 cc of 2 percent lidocaine HCL. A significant improvement in Global Symptom Score (GSS) was reported for up to 12 weeks when compared with placebo [27].
An earlier, similar study using 15 mg of methylprednisolone acetate injected into the carpal tunnel of 30 patients also resulted in improvement in the GSS for up to 12 weeks relative compared with low-dose short-term oral prednisolone [41].
Injection therapy is associated with several risks, including exacerbation of median nerve compression, accidental injection into the median or ulnar nerves, and digital flexor tendon rupture [31,42].
Corticosteroid injection versus surgery — Surgery appears to be more effective for sustained relief of symptoms from CTS than local corticosteroid injection. While short-term results of corticosteroid injection may be better than those following carpal tunnel release surgery, the advantage is lost over the course of one year following the procedure. These points are illustrated by the following studies:
* One prospective, open study randomly assigned 163 patients with symptomatic CTS to glucocorticoid injection into the carpal tunnel (20 mg of paramethasone acetonide) or surgical release (via a limited palmar incision) [43]. The main outcome was the proportion of patients in each group who had at least 20 percent improvement in nocturnal paresthesias. Significantly more of those who were assigned to injection than surgery were improved at three months (approximately 95 versus 75 percent, respectively). Over the ensuing nine months of observation, the advantage of injection over surgery was lost, while those treated surgically generally maintained the degree of improvement noted at the three-month point.
The patients in this study were predominantly Spanish housewives, and compensation for disability due to CTS was rarely an issue. Thus, the applicability of these results to patients with work-related CTS is uncertain.
* A subsequent assessor-blinded controlled trial randomly assigned 50 patients (48 were female) with CTS to a single injection of methylprednisolone 15 mg or open surgical carpal tunnel decompression [44]. At 20 weeks, surgical treatment was associated with significantly greater symptomatic improvement in the GSS score, the primary outcome, than local steroid injection (24.2 versus 8.7, respectively). The dose of methylprednisolone (15 mg) used in the trial is much less than the 40 mg most commonly used in practice.
Oral steroids — Oral corticosteroids appear to be effective for short-term improvement of CTS symptoms. In a 2003 systematic review, analysis of pooled data from three trials of high and moderate methodologic quality showed that two weeks of oral steroid treatment was associated with a statistically significant reduction in symptoms as measured by the GSS compared with placebo (weighted mean difference [WMD] -7.23; 95% CI -10.31 to -4.14); one trial showed that four weeks of oral steroid treatment was associated with a statistically significant reduction in symptoms (WMD -10.8; 95% CI -15.26 to -6.34) [20].
There are only limited data regarding the long-term effect of oral steroids for CTS treatment. In one clinical trial that evaluated two to four weeks of treatment with up to 20 mg per day of oral prednisolone, patients showed clinical and electrodiagnostic improvement for up to 12 months [45]. However, this study did not have a placebo control group. In another clinical trial, patients treated with oral prednisolone 25 mg daily for 10 days showed symptomatic improvement in CTS for up to eight weeks [41]. However, oral prednisolone was less effective than corticosteroid injection. In a placebo-controlled trial that evaluated patients with mild to moderate CTS, two weeks of oral prednisone (20 mg daily for seven days, followed by 10 mg per day for seven days) was associated with significant improvement in symptoms as measured by the GSS, but the benefit gradually waned over eight weeks of observation [14].
Yoga — Limited evidence suggests that yoga may be beneficial for pain control in patients with CTS. A preliminary assessor-blinded controlled trial randomly assigned 42 patients with CTS to eight weeks of treatment with yoga or wrist splinting. The yoga intervention consisted of 11 yoga postures designed for strengthening, stretching, and balancing each joint in the upper body along with relaxation given twice weekly [46]. Patients in the yoga group had statistically significant pain reduction compared with patients in the wrist splint group.
Carpal bone mobilization — Carpal bone mobilization is a physical and occupational therapy technique that involves movement of the bones and joints in the wrist. Data are limited, but a small trial involving 21 people found that carpal bone mobilization significantly improved symptoms (assessed using a symptom diary with a visual analog scale) after three weeks compared with no treatment (WMD -1.43; 95% CI -2.19 to -0.67) [20,47]. However, there was no significant benefit in short-term pain or hand function.
Nerve gliding — Nerve and tendon gliding exercises or maneuvers are performed under the direction of an occupational therapist with subspecialty certification in hand therapy (CHT). Nerve gliding is predicated on restoring normal movement of the median nerve. It is thought that nerve compression may lead to "tethering" of the median nerve, resulting in decreased nerve excursion and increased mechanical strain [2]. Reduced sliding of the median nerve in the transverse [16,48,49] and longitudinal [16,50] planes has been observed in CTS patients [2,16].
Data regarding nerve gliding are limited to a few small studies with equivocal results. Nerve gliding exercises alone were reported to decrease pain and increase range of motion in one study [47]. Other studies have suggested that nerve gliding in combination with splinting may allow surgery to be avoided [19] and improve patient satisfaction [16,19]. However, a prospective, randomized, unblinded trial involving 36 patients found that nerve and tendon gliding exercises for four weeks provided no statistically significant benefit at eight weeks compared with wrist splinting for symptom improvement or patient satisfaction [18].
Ultrasound therapy — Ultrasound and electrical stimulation have been used to promote recovery after nerve and tendon injuries [51]. Ultrasound is used to promote soft tissue healing and the transdermal delivery of medications at intensities ranging from 0.5 to 1.5 w/cm2. At its lower intensity range, ultrasound induces changes in cell permeability, termed "microstreaming", that are thought to enhance the healing response. At its upper range, ultrasound raises tissue temperature while reducing pain, increases tissue elasticity, and decreases tissue viscosity [51].
Data regarding the benefit of ultrasound for CTS are conflicting, although its effectiveness may depend on the duration of therapy. A 2003 systematic review, analyzing pooled data from two trials with 63 participants, found that ultrasound treatment for two weeks was not significantly beneficial [20]. However, one trial showed that ultrasound treatment for seven weeks was associated with significant symptom improvement (WMD -0.99; 95% CI -1.77 to -0.21), and the benefit was maintained at six months (WMD -1.86; 95% CI -2.67 to -1.05).
The effectiveness of ultrasound may depend on the characteristics of the ultrasound used [10,20]. Deep, pulsed ultrasound has been reported to decrease pain and improve sensory loss, nerve conduction parameters, and strength [10,52]. Continuous superficial ultrasound does not improve patients' symptoms or median nerve conduction parameters [10,53].
NSAIDS and other oral medications — A 2003 systematic review [20] found one randomized controlled trial [15] that demonstrated no significant benefit for nonsteroidal anti-inflammatory drugs (NSAIDS) when compared with placebo for improving CTS symptoms.
The available data suggest no benefit for diuretics [15,20] or vitamin B6 [20] for improving CTS symptoms.
Electrical, magnetic, and laser therapy — No clear hypotheses have been generated to support the use of any of these modalities for the treatment of CTS.
Only anecdotal evidence exists regarding electrical stimulation for the treatment of CTS. A single session of magnetic therapy was not effective when compared with sham therapy [10,54], and prolonged magnetic therapy was not effective compared with placebo [10,20,55]. Similarly, low-level laser therapy has not been proven in a controlled study design [10,20,56].
Conservative treatment choices — For patients with mild to moderate symptomatic CTS, we recommend nocturnal wrist splinting as preferred initial medical therapy because limited evidence suggests it is effective for short-term symptom relief. It is also safe and well-tolerated. (See "Wrist splinting" above).
Although evidence is limited, combined treatment employing splinting in combination with corticosteroid injection(s), oral steroids, or other conservative interventions may provide additional symptomatic relief and avoid the need for surgical decompression. (See "Treatment" above).
For patients with mild to moderate symptomatic CTS who do not tolerate or respond to splinting, we suggest treatment with corticosteroid injection or oral corticosteroid treatment. Oral steroid treatment should not extend beyond four weeks duration because of the deleterious side effects of prolonged corticosteroid therapy. (See "Corticosteroid injection" above and see "Oral steroids" above).
Limited data suggest that yoga and carpal bone mobilization may be reasonable alternative options for conservative treatment if available. (See "Yoga" above and see "Carpal bone mobilization" above).
Pregnancy — CTS may develop during pregnancy, particularly during the third trimester. In most cases, the symptoms gradually resolve over a period of weeks after delivery. For women who develop CTS during pregnancy, we recommend nocturnal wrist splinting. Surgical decompression is rarely indicated during pregnancy since the disease often resolves postpartum. (See "Neurologic disorders complicating pregnancy", section on Carpal tunnel syndrome).
Surgery — Surgical decompression is effective treatment for CTS, as evidenced by improved subjective and objective long-term measures [22,28,57,58]. (See "Splinting versus surgery" above and see "Corticosteroid injection versus surgery" above).
Additional data supporting this conclusion come from a study that systematically reviewed 209 articles published from 2000 to 2006 with patient-reported outcomes for 32,936 operations for CTS [59]. Surgery was considered successful for the outcomes of "cure", "much better", "80 percent improvement", and "satisfactory". Although there was wide variation in success rates among individual studies (range, 27 to 100 percent), the pooled success rate of surgery was 75 percent.
For patients with moderate to severe persistent CTS symptoms (eg, numbness and pain, diminished hand function, or thenar eminence atrophy), particularly those with long duration of symptoms (greater than six months) and confirmatory electrodiagnostic evidence of median nerve injury, we suggest surgical decompression. Surgery prior to six months may be reasonable for patients who do not improve despite adequate trials of conservative therapy, or whose symptoms recur after initial improvement with conservative therapy.
Surgery for CTS is discussed in greater detail separately. (See "Surgery for carpal tunnel syndrome").
SUMMARY AND RECOMMENDATIONS — For patients with mild to moderate carpal tunnel syndrome (CTS), effective conservative treatment options for short-term improvement include splinting, corticosteroids injected into the carpal tunnel, and oral corticosteroids. Carpal bone mobilization and yoga may also be beneficial. Combined therapy may be more effective than the use of any single modality. Referral to an occupational therapist with subspecialty certification in hand therapy (CHT) may improve outcomes. (See "Treatment" above).
* Unproven CTS treatments include nerve-gliding maneuvers, ultrasound, electrical stimulation, low-level laser therapy, magnetic therapy, contrast baths, and myofascial massage. Ineffective CTS treatments include nonsteroidal antiinflammatory medications (NSAIDS), vitamin B6, and diuretics. (See "Treatment" above).
* Clinical features associated with failure of conservative CTS therapy include duration of symptoms >10 months, age >50, constant paresthesias, impaired two-point discrimination (>6 mm), positive Phalen's sign <30 seconds, and prolonged motor and sensory latencies. (See "Treatment" above).
* For untreated patients with mild to moderate symptomatic CTS of ≤10 months duration, we recommend nocturnal wrist splinting in the neutral position as initial therapy in preference to other conservative measures (Grade 1B). (See "Wrist splinting" above).
* For patients who comply with nocturnal splinting, but remain symptomatic at one month, we suggest continuation of splinting for another one to two months while adding a different conservative modality as discussed below, rather than stopping splinting (Grade 2C). (See "Treatment" above).
* For patients with CTS with an inadequate response to wrist splinting, we suggest a single injection with methylprednisolone (40 mg) as the next therapeutic option rather than oral steroids (Grade 2B). For patients who decline injection therapy, we suggest treatment with oral corticosteroids (Grade 2B). We use prednisone 20 mg daily for 10 to 14 days. (See "Corticosteroid injection" above and see "Oral steroids" above).
* For patients with mild to moderate CTS who decline treatment with corticosteroids, we suggest treatment with other conservative measures including carpal bone mobilization or yoga (Grade 2C). (See "Carpal bone mobilization" above and see "Yoga" above.
* We recommend NOT using nonsteroidal antiinflammatory medication for the treatment of CTS (Grade 1B). (See "NSAIDS and other oral medications" above).
* Surgery appears to be more effective than splinting or corticosteroid injection for sustained CTS symptom relief. For patients with moderate to severe CTS that is refractory to conservative measures, we suggest surgical decompression (Grade 2B). (See "Splinting versus surgery" above, see "Corticosteroid injection versus surgery" above and see "Surgery for carpal tunnel syndrome").
ACKNOWLEDGMENT — The authors and editorial staff at UpToDate would like to acknowledge Robert P Sheon, MD, who contributed to an earlier version of this topic review.
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