Carpal tunnel syndrome. Part I: effectiveness of nonsurgical treatments--a systematic review.

OBJECTIVE: To review literature systematically concerning effectiveness of nonsurgical interventions for treating carpal tunnel syndrome (CTS). DATA SOURCES: The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs). STUDY SELECTION: Two reviewers independently applied the inclusion criteria to select potential studies. DATA EXTRACTION: Two reviewers independently extracted the data and assessed the methodologic quality. DATA SYNTHESIS: A best-evidence synthesis was performed to summarize the results of the included studies. Two reviews and 20 RCTs were included. Strong and moderate evidence was found for the effectiveness of oral steroids, steroid injections, ultrasound, electromagnetic field therapy, nocturnal splinting, and the use of ergonomic keyboards compared with a standard keyboard, and traditional cupping versus heat pads in the short term. Also, moderate evidence was found for ultrasound in the midterm. With the exception of oral and steroid injections, no long-term results were reported for any of these treatments. No evidence was found for the effectiveness of oral steroids in long term. Moreover, although higher doses of steroid injections seem to be more effective in the midterm, the benefits of steroids injections were not maintained in the long term. For all other nonsurgical interventions studied, only limited or no evidence was found. CONCLUSIONS: The reviewed evidence supports that a number of nonsurgical interventions benefit CTS in the short term, but there is sparse evidence on the midterm and long-term effectiveness of these interventions. Therefore, future studies should concentrate not only on short-term but also on midterm and long-term results.

Carpal tunnel syndrome. Part II: effectiveness of surgical treatments--a systematic review.

OBJECTIVE: To present an evidence-based overview of the effectiveness of surgical and postsurgical interventions to treat carpal tunnel syndrome (CTS). DATA SOURCES: The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs). STUDY SELECTION: Two reviewers independently applied the inclusion criteria to select potential studies. DATA EXTRACTION: Two reviewers independently extracted the data and assessed the methodologic quality. DATA SYNTHESIS: A best-evidence synthesis was performed to summarize the results of the included studies. Two reviews and 25 RCTs were included. Moderate evidence was found in favor of surgical treatment compared with splinting or anti-inflammatory drugs plus hand therapy in the midterm and long term, and for the effectiveness of corticosteroid irrigation of the median nerve before skin closure as additive to carpal tunnel release in the short term. Limited evidence was found in favor of a double-incision technique compared with the standard incision technique. Also, limited evidence was found in favor of a mini-open technique assisted by a Knifelight instrument compared with a standard open release at 19 months of follow-up. However, in the short term and at 30 months of follow-up, no significant differences were found between the mini-open technique assisted by a Knifelight instrument compared with a standard open release. Many studies compared different surgical interventions, but no evidence was found in favor of any one of them. No RCTs explored the optimal timing strategy for surgery. No evidence was found for the efficacy of various presurgical or postsurgical treatment programs, including splinting. CONCLUSIONS: Surgical treatment seems to be more effective than splinting or anti-inflammatory drugs plus hand therapy in the midterm and long term to treat CTS. However, there is no unequivocal evidence that suggests one surgical treatment is more effective than the other. More research is needed to study conservative to surgical treatment in which also should be taken into account the optimal timing of surgery. Future research should also concentrate on optimal presurgical and postsurgical treatment programs.

Effectiveness of interventions of specific complaints of the arm, neck, and/or shoulder: 3 musculoskeletal disorders of the hand. An update.

OBJECTIVES: To provide an evidence-based overview of the effectiveness of conservative and surgical interventions for trigger finger, Dupuytren's, and De Quervain's diseases. DATA SOURCES: The Cochrane Library, PEDro, PubMed, Embase, and CINAHL were searched to identify relevant studies. STUDY SELECTION: Two reviewers independently applied the inclusion criteria to select potential relevant studies from the title and abstracts of the references retrieved by the literature search. Relevant (Cochrane) reviews and randomized controlled trials (RCTs) were included. DATA EXTRACTION: Two reviewers independently extracted the data and performed a methodologic quality assessment. DATA SYNTHESIS: A best-evidence synthesis was performed to summarize the results of the included trials. One Cochrane review (trigger finger) and 13 RCTs (trigger finger [6], Dupuytren's [4], De Quervain's [3]) were included. The trials reported on physiotherapy (De Quervain's), steroid injections (trigger finger, De Quervain's), surgical treatment (trigger finger, De Quervain's), and a postsurgical treatment (Dupuytren's). For trigger finger, moderate evidence was found for the effectiveness of steroid injections in the short-term (1-4 wk) but not for long-term outcomes. Limited evidence was found for the effectiveness of staples compared with sutures in skin closure and for intermittent compression after surgery to treat Dupuytren's disease. For other interventions, no evidence was found. CONCLUSIONS: Indications for effectiveness of some interventions for trigger finger, Dupuytren's, and De Quervain's diseases were found. Because only a few RCTs were identified, it is difficult to draw firm conclusions. High-quality RCTs are clearly needed in this field.

Effectiveness of interventions of specific complaints of the arm, neck, or shoulder (CANS): musculoskeletal disorders of the hand.

OBJECTIVES: The aim of this study was to provide an evidence-based overview of the effectiveness of (conservative and surgical) interventions for the 4 specific pain disorders of the hand: trigger finger, primary Raynaud's phenomenon, Dupuytren disease, and De Quervain's disease. This information can help clinicians in the selection of interventions in daily practice, and may give direction to future research. METHODS: Relevant review publications and randomized clinical trials (RCTs) in PubMed were searched. Data extraction and quality assessment were performed. To summarize the results of the included reviews and RCTs, a best-evidence synthesis was used. RESULTS: For primary Raynaud's phenomenon (1 review, 20 RCTs), we found strong evidence for calcium channel blockers and moderate evidence for laser therapy. Limited evidence was found for Ketanserin, Prozasin, Buflomedil, transdermal glyceryl trinitrate patches, Ginkgo biloba, and behavioral treatment with temperature feedback. Other interventions did not show clear favorable treatment effects. For Trigger finger one very small RCT was found that showed limited evidence for steroid injection. For Dupuytren disease (4 RCTs) limited evidence was found in favor of use of staples versus sutures in the Dupuytren's surgery, and for intermittent compression on the postoperative hand after surgery. For other interventions no clear positive effects could be demonstrated. For De Quervain's disease (2 RCTs), we found no efficacy of Nimesulide as addition to a Triamcinolone injection, and no clear differences between a corticosteroid injection and a splint in pregnant patients or patients breast-feeding. DISCUSSION: Well-designed and well-conducted RCTs are clearly needed in this field.