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

 

Abstract

Background

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.

Objectives

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.

Search methods

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.

Selection criteria

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.

Data collection and analysis

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.

Main results

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.

Authors' conclusions

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.

 

Plain language summary

Oral steroids, splinting, ultrasound, yoga and wrist mobilisation provide short-term relief from carpal tunnel syndrome, but other non-surgical methods have not been shown to help.

Carpal tunnel syndrome is caused by compression of the median nerve at the wrist, leading to mild to severe pain and pins and needles in the hand. Other Cochrane reviews show benefit from nerve decompression surgery and steroids. This review of other non-surgical treatments found some evidence of short-term benefit from oral steroids, splinting/hand braces, ultrasound, yoga and carpal bone mobilisation (movement of the bones and tissues in the wrist), and insulin and steroid injections for people who also had diabetes. Evidence on ergonomic keyboards and vitamin B6 is unclear, while trials so far have not shown benefit from diuretics, non-steroidal anti-inflammatory drugs, magnets, laser acupuncture, exercise or chiropractic.

 

摘要

背景

以非手術的方式(也非注射類固醇)治療腕隧道症候群

輕度到中度的腕隧道症候群病人常被建議採取非手術性的治療，但非手術性治療對腕隧道症候群的有效性和效果的持久性還沒有得到證實。

目標

評估非手術治療(也非類固醇注射)與安慰劑或其他非手術治療控制組比較，對於腕隧道症候群的臨床療效。

搜尋策略

我們搜尋了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，還有文章後的參考文獻。

選擇標準

挑選出有下列特性的論文: 隨機或半隨機的研究、任何語言、以沒有開過刀的腕隧道症候群的病人為研究對象。我們納入所有沒有使用局部類固醇注射的非手術治療。主要的結果指標是治療結束追蹤至少三個月後，臨床症狀進步的情形。

資料收集與分析

三個評論者獨立地挑選要包含進來的試驗，兩個評論者獨立地從試驗中取得數據。試驗的整體品質也被評分。評論者並且計算出各個試驗主要結果指標和次要結果指標的相對危險和weighted mean differences with 95% conficence intervals。我們還把臨床和統計上同質性高試驗的結果匯集起來以估計非手術性治療的有效性。

主要結論

最後包含了21個試驗，884個人。手腕支架 顯著地在四個星期的治療後改善了症狀(weighted mean difference(WMD) −1.07; 95% condifence interval (CI) −1.29 至 −0.85), 和功能 (WMD −0.55; 95% CI −0.82 至 −0.28)。將兩個試驗、63個病人的數據匯集起來分析後，為時兩週的超音波治療沒有顯著的好處。然後一個試驗顯示七週的超音波治療造成了顯著的症狀改善(WMD −0.99; 95% CI −1.77 至 −0.21), 而且這個好處到六個月都存在(WMD −1.86; 95% CI −2.67 至 −1.05)。四個試驗，共含193個人，檢驗了各種口服藥物(類固醇、利尿劑、非類固醇類消炎藥)和安慰劑的療效差異。和安慰劑相比，匯集起來的數據顯示二週的口服類固醇可以顯著地改善症狀(WMN −7.23; 95% CI −10.31 至 −4.14)。另一個試驗也顯示四週的治療有效(WMD −10.8; 95% CI −15.26 to −6.34)。和安慰劑相比，利尿劑或非類固醇類消炎藥沒有顯著的好處。在兩個共含50個人的試驗中，維他命B6沒有辦法顯著地改善症狀。在一個含51個人的試驗中，瑜珈和手腕護木相比，在八週後可以顯著地減少疼痛(WMD −1.40; 95% CI −2.73 to −0.07)。在一個包含了21個人的試驗中，腕骨鬆動術和完全不治療相比，顯著地在三週後改善了症狀((WMD −1.43; 95% CI −2.19 to −0.67)。在一個包含了50個糖尿病病人的試驗中，類固醇加胰島素在八週的治療中，和類固醇加安慰劑相比，顯著地改善了症狀。兩個共包含105人的試驗比較了人體工學鍵盤和控制組的差別，在疼痛和功能方面沒有得到明確的結果。研究磁力治療、雷射針灸、運動或是整脊治療的研究未能顯示它們相對於安慰劑或是控制組有明確的症狀改善。

作者結論

現有的證據顯示口服類固醇、護木固定、超音波、瑜珈、及腕骨鬆動術有顯著的短期效果。其他非手術的治療未能產生顯著的療效。未來需要更多試驗來比較各種治療間的差異，並確定療效的時間長短。

翻譯人

本摘要由新光醫院葉旭霖翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

口服類固醇、護木固定、超音波、瑜珈和腕骨鬆動術能造短期緩解腕隧道症候群的症狀，但是其他非手術性的治療則沒有幫助。腕隧道症候群是由腕部正中神經的壓迫所造成，導致手部輕微至嚴重的疼痛還有類似針刺的麻痛感。其他Cochrane評論顯示神經減壓手術和類固醇有好處。這篇關於非手術性治療的評論發現使用口服類固醇、使用手部石膏/支架、超音波、瑜珈，及腕骨鬆動術(使腕部的骨頭和組織產生移動)有短期的好處，而對同時有糖尿病的病人來說，注射類固醇和胰島素有好處。關於人體工學鍵盤和維他命B6的證據尚不清楚，到目前為止的試驗也沒有顯示利尿劑、非類固醇類消炎藥、磁力、雷射針灸、運動、或是整脊有什麼好處。