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Rehabilitation following carpal tunnel release

  1. Susan Peters1,2,*,
  2. Matthew J Page3,
  3. Michel W Coppieters1,
  4. Mark Ross2,4,
  5. Venerina Johnston1

Editorial Group: Cochrane Neuromuscular Disease Group

Published Online: 5 JUN 2013

Assessed as up-to-date: 3 APR 2012

DOI: 10.1002/14651858.CD004158.pub2

How to Cite

Peters S, Page MJ, Coppieters MW, Ross M, Johnston V. Rehabilitation following carpal tunnel release. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD004158. DOI: 10.1002/14651858.CD004158.pub2.

Author Information

  1. 1

    The University of Queensland, Division of Physiotherapy, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia

  2. 2

    Brisbane Hand and Upper Limb Research Institute, Brisbane, Queensland, Australia

  3. 3

    Monash University, School of Public Health & Preventive Medicine, Melbourne, Victoria, Australia

  4. 4

    The University of Queensland, Division of Orthopaedic Surgery, School of Medicine, Brisbane, Queensland, Australia

*Susan Peters, Brisbane Hand and Upper Limb Research Institute, Level 9, 259 Wickham Terrace, Brisbane, Queensland, QLD 4000, Australia. Research@upperlimb.com.

Publication History

  1. Publication Status: New
  2. Published Online: 5 JUN 2013

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Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Description of the condition

Carpal tunnel syndrome (CTS) is a neurological condition resulting from compression of the median nerve at the wrist due to increased pressure within the carpal tunnel (AAOS 2007; Phalen 1966). Patients with CTS usually present with sensory or motor symptoms, or both, in the hand and wrist. Patients often experience pain, paraesthesia or numbness in the distal distribution of the thumb, index, middle and radial half of the ring finger (Phalen 1966; Rempel 1998). Extramedian spread of sensory and pain symptoms has been reported in 37.5% of patients (Zanette 2010). In advanced stages, wasting of the thenar muscles and hand weakness is observed (Ibrahim 2012).

CTS is one of the most common disorders of the upper extremity (AAOS 2007). The prevalence of CTS in the general population is 3.8% when diagnosed clinically and 2.7% when diagnosed neurophysiologically (Atroshi 1999). There is a higher prevalence in women than in men (Gelfman 2009). Whilst some authors have indicated that occupational risk factors, such as vibration, force and repetition (Barcenilla 2012; Burt 2011; Herbert 2000); and certain occupations (Armstrong 2008; Kim 2004; Wyatt 2012) contribute to CTS, there is still some controversy regarding its work-relatedness (Stapleton 2006). Other risk factors for CTS have been suggested, such as obesity, diabetes, previous wrist fracture and arthritis (Geoghegan 2004; Lam 1998; Palmer 2007; Van Rijn 2009).

CTS can be treated both nonsurgically (conservatively) or surgically. Conservative treatment options are usually offered to individuals who experience milder or intermittent symptoms, are pregnant, or who cannot or choose not to have surgery (Page 2012a). Many different nonsurgical interventions may be offered, including therapeutic ultrasound, splinting, exercise prescription, mobilisation techniques, ergonomic modification, oral medication, corticosteroid injections, vitamins and complementary therapies (Marshall 2007; O'Connor 2012; Page 2012a; Page 2012b; Page 2012c). Few have any proven therapeutic benefit.

CTS surgery is most commonly referred to as carpal tunnel release (CTR). CTR may be indicated for individuals with persistent symptoms that have not responded to conservative management, those presenting with more severe symptoms (such as frequent numbness or thenar muscle wasting) or those with electrophysiologically severe disease (Scholten 2007; Verdugo 2008). Surgery involves the division of the transverse carpal ligament to increase the volume of the carpal tunnel, thereby reducing pressure on the median nerve (Aroori 2008). In the United States of America, approximately 40% of patients with CTS are treated operatively (Wilson 2003), whilst 31% of persons with CTS have surgery in the United Kingdom (Latinovic 2006). CTR has a reported long-term success rate of 75% to 90% (Louie 2012).

Two surgical approaches are commonly used to release the transverse carpal ligament: open CTR and endoscopic CTR. Open CTR divides the carpal tunnel ligament using a palmar incision. In recent years, minimal-incision-open (or mini-open) techniques have become more common in an attempt to minimise surgical trauma, iatrogenic symptoms from the surgery and recovery time (Bromley 1994). Over time, several variations of these techniques have developed to reduce postoperative pain, improve function and shorten recovery time. A number of secondary procedures may be performed concurrently. These include techniques such as epineurotomy, internal neurolysis, synovectomy and reconstruction of the transverse carpal ligament (Huisstede 2010). Endoscopic CTR (ECTR) involves division of the transverse carpal ligament whilst leaving the overlying structures intact. This is believed to reduce postoperative pain and scarring and hasten early return to function and work (Sanati 2011). Two techniques are commonly used for ECTR: the single portal technique (Agee 1992) and the two portal technique (Chow 1989).

Complications following CTR may include nerve injury, neuroma formation, palmar arch injury, hematomas, complex regional pain syndrome, tendon adhesions, bowstringing of the flexor tendons, pillar pain, scar pain and other iatrogenic complications as a result of the surgery (Braun 2002). Furthermore, symptoms of CTS may recur or persist following surgical release (Gerritsen 2001; Hunter 1991; Idler 1996). Reasons for persistence of symptoms following surgical release include incorrect diagnosis, inadequate decompression of the median nerve, iatrogenic compression or nerve injury, double crush syndrome, and end-stage disease (Idler 1996; Louie 2012). The prognosis following CTS has been associated with a number of factors, such as age, psychological factors, workers compensation, duration of CTS symptoms, presence of thenar atrophy and absence of sensory and motor nerve conduction (Amick 2004; Bland 2001; Cowan 2012; Finestone 1996). The presence of other disorders, such as rheumatoid arthritis and diabetes, may also affect the prognosis (DeStefano 1997).

 

Description of the intervention

Various rehabilitation treatments may be recommended following CTR. These interventions are believed to expedite recovery by improving mobility, strengthening the hand and promoting earlier return to function and work (Pomerance 2007; Provinciali 2000). Interventions may also be prescribed to manage the iatrogenic symptoms of the surgery including control of postoperative swelling, scar desensitisation, management of pillar pain and wound healing (Janssen 2009; Powell 2003; Ritting 2012). Therefore, postoperative rehabilitation might include interventions such as provision of advice, exercise prescription, mobilisation techniques, splinting of the wrist using an orthosis, wound and scar management, oedema management, electrotherapy, cryotherapy, desensitisation, ergonomic modification, strengthening and work modification (Groves 1989; Nathan 1993). These interventions may be provided as stand-alone interventions or as part of a program of rehabilitation treatments.

 

How the intervention might work

The goal of postoperative rehabilitation is to speed up and enhance symptom resolution and functional recovery following surgery. Various arguments in support of the individual rehabilitative techniques have been reported. For instance, immobilisation of the wrist with an orthosis has been recommended to minimise postoperative pain, wound dehiscence, nerve entrapment, and prevent bowstringing of the flexor tendons (Bury 1995; Jessurun 1988). Laser therapy and modalities that use electrical stimulation have been advocated to stimulate wound healing, neuronal regeneration and control pain postoperatively (Alves 2011; Gordon 2010 ). Lighter postoperative dressings are advocated to allow easier and earlier mobilisation of the hand and wrist (Ritting 2012). Advocates of early mobilisation following surgery propose that motion of the wrist and digits promotes longitudinal gliding of the median nerve through the surgical bed and prevents adhesion formation between the nerve and flexor tendons (Nathan 1993; Skirven 1994). Oedema management techniques are used to minimise the inflammatory response on digital range of motion (Hayes 2002). Scar management techniques, such as massage, pressure, and the application of silicon-based products, are advocated to loosen adhesions between skin and underlying tissues, aid in the desensitisation of the incisional scar and promote scar remodelling (Hayes 2002; Powell 2003). Strengthening exercises and progressive functional activities are incorporated into the rehabilitative program to maximise occupational performance following surgery (Hayes 2002; Nathan 1993). Some authors advocate the use of comprehensive multi-component therapy programs (consisting of various rehabilitation treatments, such as advice, mobilisation and management of iatrogenic symptoms from the surgery by physiotherapists or occupational therapists who specialise in hand therapy) to promote early return to function and work (Nathan 1993). Nathan 1993 also found that compliance with hand therapy was the strongest prognostic factor for early return to function and work.

 

Why it is important to do this review

The evidence base for rehabilitation following CTR has grown. Three reviews of specific treatments following CTR have been published (Huisstede 2010; Isaac 2010; Keilani 2002). Cochrane systematic reviews of various nonsurgical interventions (Marshall 2007; O'Connor 2012; Page 2012a; Page 2012b; Page 2012c) and surgical treatment options (Scholten 2007; Verdugo 2008) for CTS already exist. However, no Cochrane systematic review on rehabilitation treatments following surgical management of CTS has been conducted. There are many rehabilitation treatments which may be offered to patients who have had CTR. As there is limited evidence or guidelines for the use of any of these interventions, a Cochrane systematic review is warranted.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

The objective of this review was to compare the effectiveness and safety of various rehabilitation treatments provided following CTR with no treatment, placebo or another treatment.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Criteria for considering studies for this review

 

Types of studies

All published and unpublished studies using or attempting to use a randomised methodology that compared a postoperative treatment with no treatment (or a placebo) or with another rehabilitation treatment.

We excluded studies that compared surgery to rehabilitation interventions or any interventions provided before surgery and interventions that were not considered to be a rehabilitation treatment, for example postoperative analgesia. There were no restrictions by year of publication or language.

 

Types of participants

All participants with a diagnosis of CTS (as defined by the authors of each study) who underwent CTR, either endoscopically or with any form of open technique.

 

Types of interventions

All postoperative rehabilitation treatments including: the provision of advice, exercise, use of a hand or wrist orthosis, scar management, oedema management, electrotherapy, desensitisation, ergonomic modification, work modification, exercise prescription and return-to-work interventions.

We excluded any intervention that occurred before surgery or at the time of surgery, for example, type of anaesthetic or suture type. We also excluded postoperative analgesia.

 

Types of outcome measures

We modified outcomes from the original protocol (O'Connor 2003) for this review. We have detailed changes in the section Differences between protocol and review.

 

Primary outcomes

  1. Long-term change in self reported functional ability as measured on a continuous scale (for example, Functional Scale from the Boston Carpal Tunnel Questionnaire (BCTQ) or Disabilities of the Arm, Shoulder and Hand questionnaire (DASH)). Long-term was defined as three months or longer.

 

Secondary outcomes

  1. Short-term change in self reported functional ability as measured on a continuous scale (for example, Functional Scale from BCTQ or DASH). Short-term was defined as less than three months;
  2. Short-term (less than three months) and long-term (three months or more) change in CTS clinical symptoms as measured on a continuous scale (for example, pain, numbness and paraesthesia);
  3. Short-term (less than three months) and long-term (three months or more) change in CTS related impairment measures (for example, grip and pinch strength);
  4. Presence of iatrogenic symptoms secondary to CTR (for example, swelling, scar pain, excessive scarring and pillar pain) at short-term (less than three months) and long-term (three months or more) follow-up;
  5. Return to work or occupation (measured as 'yes' or 'no') at three months;
  6. Short-term (less than three months) and long-term (three months or more) change in neurophysiologic parameters (using nerve conduction studies);
  7. Presence of adverse events as a result of the rehabilitation at short-term (less than three months) and long-term (three months or more) follow-up. 

 

Search methods for identification of studies

 

Electronic searches

On 3 April 2012, we searched the Cochrane Neuromuscular Disease Group Specialized Register (3 April 2012) for randomised trials using 'carpal tunnel syndrome' and 'rehabilitation' as the primary search terms. In addition, we searched CENTRAL (2012 Issue 3 in the Cochrane Library), MEDLINE (January 1966 to March 2012), EMBASE (January 1980 to March 2012), CINAHL Plus (January 1937 to March 2012), AMED (January 1985 to January 2012), LILACS (January 1982 to March 2012), PsycINFO (January 1806 to March 2012), PEDRO (January 1999 to January 2013), WHO International Clinicial Trials Registry Platform (ICTRP) (29 January 2013), UK Clinical Research Network Study Portfolio (5 April 2012) and ClinicalTrials.gov Database (29 January 2013).

The detailed search strategies are detailed in the appendices: Appendix 1 (MEDLINE), Appendix 2 (EMBASE), Appendix 3 (AMED), Appendix 4 (PsycINFO), Appendix 5 (CINAHL Plus), Appendix 6 (LILACS) and Appendix 7 (CENTRAL), PEDRO (Appendix 8).

 

Searching other resources

We searched bibliographies of relevant trials identified by this strategy. Where possible, we contacted authors of identified papers to determine whether other published or unpublished trials were available.

 

Data collection and analysis

The review authors followed the recommended strategies for data collection and analysis documented in Chapters 7 and 9 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

 

Selection of studies

Two review authors independently selected the trials for possible inclusion against a predetermined checklist of inclusion criteria (see Criteria for considering studies for this review). Each review author independently examined the titles and abstracts of trials for possible inclusion identified from the search and categorised studies into the following groups.

  • Possibly relevant: studies that met the inclusion criteria and studies from which it was not possible to determine whether they met the criteria either from their title or abstract.
  • Excluded: studies that did not meet the inclusion criteria.

The two review authors then independently reviewed the full text of all studies for possible relevance. Each of these review authors compiled a list of trials that met the inclusion criteria. The review authors compared the lists and a third review author resolved any discrepancies that could not be resolved through discussion.

 

Data extraction and management

The two review authors independently extracted the data using a data extraction form specifically developed for this review. The authors resolved any discrepancies through discussion until consensus was reached. We piloted and accordingly modified the data extraction form prior to its use. In addition to collecting the relevant data to perform the risk of bias assessment and study results, we collected the following information for each study:

  • details of the participant sample (age, sex, diagnostic criteria used to confirm CTS, severity of symptoms, duration of symptoms, details of surgical intervention, recruitment method, inclusion and exclusion criteria, number of participants or wrists randomised);
  • types of interventions used and comparison groups (description of interventions, method of delivery, duration);
  • outcome measures (description and timing).

Two review authors compiled all comparisons and entered the outcome data into the Cochrane statistical software (Review Manager 5.2 (RevMan 2012)) for meta-analysis. Another review author cross-checked the entered data for accuracy. One review author obtained missing data from the trial authors wherever possible. When these efforts were unsuccessful, we included the study in the review and described it fully, but did not include it include in the meta-analysis. We entered a description of this process in the notes section of the Characteristics of included studies table.

 

Assessment of risk of bias in included studies

Two review authors independently assessed the included trials using the 'Risk of bias' tool described in Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We assessed the following items:

  • random sequence generation;
  • allocation concealment;
  • blinding of participants and study personnel;
  • blinding of outcome assessment;
  • incomplete outcome data (defined separately for data measured at less than three months, and three months or more);
  • selective reporting;
  • other sources of bias.

We rated each item as at 'Low risk', 'Unclear risk', or 'High risk' of bias. When criteria were unclear, one review author attempted to obtain further information from the authors of the trial. The review authors resolved any discrepancies by discussion.

 

Measures of treatment effect

We expressed results as risk ratios (RR) with 95% confidence intervals (CI) for dichotomous outcomes and mean differences (MD) with 95% CIs for continuous outcomes if the same measurement tool was used across separate studies. Alternatively, we used the standardised mean difference (SMD) when studies measured the same outcome with different measurement tools.

 

Unit of analysis issues

As CTS can affect either one or both hands, a unit of analysis error can occur if an appropriate statistical analysis is not used (Stanek 1996). Hence, we sought information about the unit of randomisation (participants or wrists). In studies that randomised wrists, we sought information about whether, in participants with bilateral CTS, each wrist was allocated to a different treatment, or whether there was no such constraint. Given that results are unlikely to be independent for wrists from the same participant, we assessed how the investigators accounted for this in their analyses (for example, use of paired or matched analyses, generalised estimating equations). If reports did not include this information, we contacted trialists for clarification. We also requested individual wrist outcome data from trialists to re-analyse the data.

 

Dealing with missing data

We sought missing information about study design, outcome data, or attrition rates such as drop-outs, losses to follow-up and withdrawn study participants from the authors of included studies by either mail or email. We indicated all unpublished data obtained from the trial authors in the relevant sections of this review.

 

Assessment of heterogeneity

The review authors assessed clinical heterogeneity by determining whether the characteristics of participants, interventions, outcome measures and timing of outcome measurement were similar across studies. We assessed statistical heterogeneity using the Chi2 statistic and the I2 test (Higgins 2011).

We interpreted the I2 statistic using the following boundaries as an approximate guide:

  • 0% to 40% might not be important heterogeneity;
  • 30% to 60% may represent moderate heterogeneity;
  • 50% to 90% may represent substantial heterogeneity; and
  • 75% to 100% may represent considerable heterogeneity (Deeks 2011).

 

Assessment of reporting biases

To assess small study effects, we intended to generate funnel plots if meta-analyses included at least 10 studies examining the same treatment comparison (Sterne 2011). To assess outcome reporting bias, we searched protocols of trials on the clinical trials register that is maintained by the US National Institute of Health (http://clinicaltrials.gov), and trials published after July 1st 2005 using the Clinical Trial Register, International Clinical Trials Registry Platform (ICTRP), World Health Organization (WHO) (http://apps.who.int/trialssearch), and compared these with the corresponding published randomised controlled trials (Dwan 2008; Dwan 2011).

 

Data synthesis

We performed statistical analysis using RevMan 5.2. We planned to pool results of studies with similar characteristics (participants, interventions, outcome measures and timing of outcome measurement) to provide estimates of the efficacy of specific interventions following CTR. We planned to pool results in a meta-analysis using either a fixed-effect or random-effects model (depending on the level of clinical and methodological heterogeneity). Where data could not be combined, we presented the results as a narrative synthesis. We set statistical significance at P < 0.05 for primary and secondary outcome measures.

 

Subgroup analysis and investigation of heterogeneity

We planned the following prespecified subgroup analyses to assess the effect of the severity of symptoms and type of surgical intervention:

1. Severity of CTS symptoms (Szabo 1994):

  • early CTS, defined as intermittent symptoms, no motor impairment and normal electrophysiological tests;
  • intermediate CTS, defined as constant symptoms with abnormal electrophysiological tests, with or without motor impairment;
  • advanced CTS, defined as severe loss of sensory and motor function, the presence of thenar muscle atrophy and weakness, and abnormal electrophysiological and sensory tests.

2. Type of surgical intervention:

  • endoscopic (either single portal or double portal);
  • open;
  • minimal-incision open;
  • another carpal tunnel surgery(including secondary procedures such as epineurotomy, internal neurolysis, synovectomy or reconstruction of the transverse carpal ligament).

 

Sensitivity analysis

We used predetermined sensitivity analyses to assess the effect of excluding studies when (a) allocation concealment was rated as inadequate, not used or unclear (and attempts to clarify with authors failed); (b) blinding of outcome assessment was not done or was rated as unclear (and attempts to clarify with authors failed); and (c) intention-to-treat analysis was not performed or was unclear (and attempts to clarify with authors failed). These quality criteria have been shown to influence estimates of treatment effects (Jüni 2001). 

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Description of studies

 

Results of the search

The searches conducted to April 2012 identified a total of 676 records. Table 1 reports the number of records retrieved by each search strategy. There were 472 records after removal of duplicates. We retrieved 18 potentially relevant articles from other sources (including 17 studies from clinical trials registries). We retrieved no articles from the reference lists of potentially eligible studies. From the 676 records, a total 30 full-text papers were selected for review. Of these, 20 studies met the inclusion criteria and were included in this review. Four studies are awaiting assessment (Chaise 1994; NCT00845325; NCT00435149; Gordon 2007), as these studies have not yet been fully completed, require translation or we require further information to assess their eligibility(see Characteristics of studies awaiting classification). A flow diagram of the study selection process is presented in Figure 1.

 FigureFigure 1. Study flow diagram.

 

Table 1


DatabasePeriod SearchedDate SearchedNumber of Hits

MEDLINEJanuary 1966 to March 201203 April 2012260

CINAHL PLUSJanuary 1937 to March 201203 April 201281

EMBASEJanuary 1980 to March 201203 April 2012166

AMEDJanuary 1985 to March 201203 April 201220

LILACSJanuary 1982 to March 201203 April 201225

CENTRAL2012, Issue 303 April 2012171

PsychINFOJanuary 1806 to March 201203 April 20122

Cochrane Neuromuscular Disease Group Specialized Register03 April 201203 April 2012100

ClinicalTrials.gov (www.clinicaltrials.gov)29 January 201305 April 201269

Current Controlled Trials Register (UK Trials) (www.controlled-trials.com)29 January 201305 April 201224

PEDROJanuary 1999 to January 201329 January 201378

WHO ICTRP (http://www.who.int/ictrp/en/)29 January 201329 January 201395



 

Included studies

Twenty trials met the inclusion criteria and are described in full in the Characteristics of included studies. There was a total of 1445 participants in the included studies, consisting of 279 male and 685 female participants (demographic data were missing for 481 participants). The trials presented findings across nine treatments: immobilisation using a wrist orthosis, dressings, exercise, controlled cold therapy, ice therapy, multimodal hand rehabilitation, laser therapy, electrical modalities, scar desensitisation, and arnica. The rehabilitation interventions varied in their types, intensity, duration and treatment setting. In 13 studies, participants only contributed one CTS-affected wrist to the study (Alves 2011; Cebesoy 2007; Cook 1995; Fagan 2004; Gordon 2010; Hochberg 2001; Huemer 2007; Janssen 2009; Pomerance 2007; Powell 2003; Ritting 2012; Stevinson 2003; Williams 2008). In five studies some of the participants had bilateral CTR and contributed both wrists to the analysis (Bury 1995; Finsen 1999; Jeffrey 2002; Martins 2006; Provinciali 2000). Of these, two randomised each wrist to different interventions (Finsen 1999; Martins 2006); one randomised both wrists to the same intervention (Jeffrey 2002); and the wrist allocation method was unclear in two studies (Bury 1995; Provinciali 2000). A unit of analysis error occurred in three of these studies, as no attempt was made to control the correlation between wrists (Finsen 1999; Martins 2006; Provinciali 2000). Jeffrey 2002 avoided a unit of analysis error. However, it was unclear whether a unit of analysis error occurred in Bury 1995. In two studies, it was unclear whether any participants had bilateral CTS (Bhatia 2000; Li 2008), so a unit of analysis error may have occurred.

Four of the 20 included studies reported the primary outcome for this review at three months or longer (Cebesoy 2007; Gordon 2010; Pomerance 2007; Powell 2003). However, only three studies (Cebesoy 2007; Pomerance 2007; Powell 2003) reported data in a meaningful format that allowed entry into RevMan.

Secondary outcomes were reported as follows: short-term change in self reported functional ability at less than three months was reported in four studies (Cebesoy 2007; Cook 1995; Powell 2003; Williams 2008); change in CTS clinical symptoms was the most common outcome, reported in 15 studies (Alves 2011, Bhatia 2000; Bury 1995; Cebesoy 2007; Cook 1995; Finsen 1999; Gordon 2010; Hochberg 2001; Huemer 2007; Jeffrey 2002; Martins 2006; Pomerance 2007; Powell 2003; Stevinson 2003; Williams 2008); change in CTS impairment measures (either grip or pinch strength or impairment in sensation) was measured in nine studies (Bury 1995; Cook 1995; Finsen 1999;Gordon 2010; Huemer 2007; Janssen 2009; Jeffrey 2002; Pomerance 2007; Ritting 2012); presence of iatrogenic symptoms related to CTR was assessed in 10 studies (Alves 2011; Cook 1995; Fagan 2004; Finsen 1999; Hochberg 2001; Huemer 2007; Jeffrey 2002; Martins 2006; Powell 2003; Stevinson 2003); return to work or occupation was measured in six studies, although the time interval was not always adequately defined (Alves 2011; Bury 1995; Cook 1995; Finsen 1999; Pomerance 2007; Provinciali 2000); change in neurophysiological parameters (nerve conduction studies) was recorded in two studies (Gordon 2010; Huemer 2007); and adverse events related to the rehabilitation intervention were reported in ten studies (Alves 2011; Bury 1995; Cebesoy 2007; Huemer 2007; Jeffrey 2002; Pomerance 2007; Powell 2003; Ritting 2012; Stevinson 2003; Williams 2008). In some studies, adverse events were reported as iatrogenic symptoms of the surgery, not adverse events of the rehabilitation intervention.

One of the studies (Powell 2003) was unpublished and the review authors obtained data entirely from unpublished sources (thesis and communication with the trial authors). We also obtained additional data not reported in the study publications from the trialists of the following studies: Alves 2011; Finsen 1999; Janssen 2009; Martins 2006; Provinciali 2000; Stevinson 2003; Williams 2008. A number of attempts to contact authors of other trials (Bhatia 2000; Bury 1995; Cook 1995; Fagan 2004; Gordon 2010; Hochberg 2001; Huemer 2007; Li 2008; Pomerance 2007; Ritting 2012) for clarification of information were unsuccessful.

 

Suitability of trials for meta-analysis

We were not able to statistically pool data from the included trials. This was because they were too clinically heterogeneous with respect to the type and duration of interventions and the outcome measures reported. Nine different types of postoperative rehabilitation treatments were identified in the included trials (immobilisation with wrist splint, soft bulky dressings, exercise, controlled cold therapy, ice therapy, multimodal hand rehabilitation, laser therapy, scar desensitisation and arnica). The duration of treatment varied from 48 hours (Bhatia 2000) to four weeks (Finsen 1999). In 12 trials (Bhatia 2000; Bury 1995; Cebesoy 2007; Cook 1995; Finsen 1999; Gordon 2010; Huemer 2007; Jeffrey 2002; Li 2008; Pomerance 2007; Provinciali 2000; Stevinson 2003) the data reported could not be included in the statistical analysis for a number of reasons: omission of measures of variability in reports of continuous outcomes (Bury 1995; Cook 1995; Huemer 2007; Jeffrey 2002; Pomerance 2007; Provinciali 2000), not reporting the number of participants assessed for an outcome measure (Provinciali 2000), presenting outcome data in a graphical form or other format (Gordon 2010), stating conclusions without providing supporting point estimates, measures of variability or frequency counts of outcomes (Cook 1995; Bhatia 2000; Bury 1995) or not providing CTS specific data when participants with other diagnoses were included in the study (Li 2008). Two studies reported median values and CIs indicating skewed data (Finsen 1999; Stevinson 2003) and data were not appropriate for inclusion in a standard meta-analysis.

Summary details of the trials are provided in the Characteristics of included studies.

 

Excluded studies

In total we excluded 443 studies after screening of titles and abstracts, and excluded five studies after review of the full text publication. Reasons for exclusion of studies are provided in the Characteristics of excluded studies table. The reasons for exclusion were either non-randomised study design or that post CTR interventions were not investigated.

 

Risk of bias in included studies

Full details of the 'Risk of bias' assessments are available in the 'Risk of bias' tables, and a summary is presented in Figure 2. In studies where the risk of bias was rated as 'Unclear', we made attempts to contact the trial authors to request clarification or additional data.

 FigureFigure 2. Risk of bias summary: review authors' judgements about each risk of bias item for each included study. Key: red = high risk of bias; yellow = unclear risk of bias; green = low risk of bias; blank = not applicable.

 

Allocation

Generation of the randomisation sequence was rated as at 'low risk of bias' in 11 of the included trials (Bhatia 2000; Bury 1995; Fagan 2004; Gordon 2010; Hochberg 2001; Janssen 2009; Pomerance 2007; Powell 2003; Ritting 2012; Stevinson 2003; Williams 2008). Six of these trials (Bhatia 2000; Bury 1995; Gordon 2010; Hochberg 2001; Ritting 2012; Stevinson 2003) used random number tables for determining allocation sequence, and two trials (Fagan 2004; Williams 2008) used random envelope draw. One trial (Janssen 2009) used a technique of randomly drawing coloured cubes from a bag, and two trials (Pomerance 2007; Powell 2003) drew allocation from a box or bowl. Five of the included trials (Alves 2011; Cebesoy 2007; Finsen 1999; Huemer 2007; Martins 2006) used some form of alternation (that is, a non-random sequence). Four of the studies (Cook 1995; Jeffrey 2002; Li 2008; Provinciali 2000) did not clearly report their randomisation process and attempts to obtain this information from the trial authors were unsuccessful.

Allocation concealment was rated as at 'low risk of bias' in four of the included trials (Jeffrey 2002; Pomerance 2007; Powell 2003; Stevinson 2003). In Gupta 2011, concealment was achieved by using sequentially numbered, sealed envelopes. Jeffrey 2002 and Stevinson 2003 used an external entity to conceal the allocation. Pomerance 2007 and Powell 2003 drew allocations out of a box. Allocation concealment was rated as at 'high risk of bias' in five trials (Alves 2011; Cebesoy 2007; Finsen 1999; Huemer 2007; Williams 2008). Alves 2011 and Huemer 2007 used an alternate method for assigning allocation using odd and even numbers. Finsen 1999 used participants' social security numbers to allocate them to groups. Williams 2008 used the same pieces of paper drawn alternately from an envelope. The remaining 11 studies were rated as having an unclear risk of bias, as they either did not report any method of concealing the allocation sequence or reported only some components (Bhatia 2000; Bury 1995; Cook 1995; Fagan 2004; Gordon 2010; Hochberg 2001; Janssen 2009; Li 2008; Martins 2006; Provinciali 2000; Ritting 2012). Attempts to clarify this with the trial authors were unsuccessful.

 

Blinding

Five of the included studies achieved blinding of the participants and study personnel for self reported outcomes (Alves 2011; Janssen 2009; Jeffrey 2002; Powell 2003; Stevinson 2003) and were rated as having a 'low risk of bias'. This was achieved by either delivering a 'sham' or placebo intervention, most commonly with identical looking tablets or ointments (Alves 2011; Jeffrey 2002; Stevinson 2003) or by not informing participants of the treatments offered to the other group(s) (Powell 2003). Fifteen of the included studies were not able to achieve participant blinding (Bhatia 2000; Bury 1995; Cebesoy 2007; Cook 1995; Fagan 2004; Finsen 1999; Gordon 2010; Hochberg 2001; Huemer 2007; Li 2008; Martins 2006; Pomerance 2007; Provinciali 2000; Ritting 2012; Williams 2008) and were rated as having 'high risk of bias'. However, due to the nature of these interventions (for example, wrist orthosis versus no orthosis), it is not surprising that blinding could not be achieved.

Blinding of the outcomes assessors was achieved in nine of the included studies (Janssen 2009; Jeffrey 2002; Martins 2006; Pomerance 2007; Powell 2003; Provinciali 2000; Ritting 2012; Stevinson 2003; Williams 2008). Blinding of the outcome assessors was unclear in eight studies (Bhatia 2000; Bury 1995; Cook 1995; Fagan 2004; Finsen 1999; Gordon 2010; Huemer 2007; Li 2008). In these instances, an explicit statement regarding assessor blinding was not reported in the trial description and attempts to clarify this issue with the trial authors were unsuccessful. Blinding of the outcome assessors was not adequate in three studies and hence rated as 'high risk of bias' (Alves 2011; Cebesoy 2007; Hochberg 2001).

 

Incomplete outcome data

Fourteen studies were rated as being at 'low risk of bias' for completeness of outcome data at less than three months (Alves 2011; Cebesoy 2007; Fagan 2004; Gordon 2010; Hochberg 2001; Huemer 2007; Janssen 2009; Jeffrey 2002; Li 2008; Martins 2006; Pomerance 2007; Powell 2003; Stevinson 2003; Williams 2008). Of these trials, the percentage lost to follow-up ranged up to 33% (Hochberg 2001) of randomised participants. Three studies were rated as being unclear in this domain (Bhatia 2000; Cook 1995; Provinciali 2000), and two studies were rated as at 'high risk of bias' in this domain (Finsen 1999; Ritting 2012). One trial (Bury 1995) did not evaluate any outcome measures in the time frame less than three months. Complete follow-up of the data-set was achieved in five of the included trials (Alves 2011; Cook 1995; Finsen 1999; Huemer 2007; Provinciali 2000).

Three studies were rated as being at 'low risk of bias' for completeness of outcome data at three months or longer (Alves 2011; Gordon 2010; Pomerance 2007). Two studies were rated as being unclear in this domain (Bury 1995; Cook 1995), and four were rated as having 'high risk of bias' (Bhatia 2000; Finsen 1999; Li 2008; Stevinson 2003) at one or both timepoints. Eleven studies did not evaluate any outcome measures at three months or longer (Cebesoy 2007; Fagan 2004; Hochberg 2001; Huemer 2007; Janssen 2009; Jeffrey 2002; Martins 2006; Powell 2003; Provinciali 2000; Ritting 2012; Williams 2008).

 

Selective reporting

Twelve studies (Alves 2011; Bhatia 2000; Cebesoy 2007; Hochberg 2001; Janssen 2009; Jeffrey 2002; Li 2008; Martins 2006; Powell 2003; Ritting 2012; Stevinson 2003; Williams 2008) were rated as being at 'low risk of bias' for selective reporting. Eight (Bury 1995; Cook 1995; Fagan 2004; Finsen 1999; Gordon 2010; Huemer 2007; Pomerance 2007; Provinciali 2000) were rated as being at 'high risk of bias' for selective outcome reporting as they either did not specify the results for some of the outcomes listed in the methods section, only partially reported the results or provided them in a format that was not suitable for meta-analysis.

 

Other potential sources of bias

All studies were judged as being at 'low risk of bias' for this domain, except Stevinson 2003. This study was judged as being unclear in this domain as it was not clearly reported whether the protocol violations significantly influenced the data obtained. Attempts to clarify the data from the trial authors were unsuccessful.

 

Effects of interventions

 

Low-level laser therapy (single intervention) versus "sham" therapy (placebo)

One trial, Alves 2011 examined the benefit of low-level laser therapy following CTR compared with a placebo intervention, in 58 participants. Low-level laser therapy was applied using an aluminium gallium Ibramed laser pen with a 830 nm wavelength and 30 mW power. Treatments were delivered in five daily consecutive sessions, with a rest (no treatment) interval of two days, followed by another five consecutive days of treatment. Laser was delivered with a total of 3 Joules, at three points of the carpal tunnel (pisiform, middle of the carpal tunnel and the distal limit of the carpal tunnel). Outcomes were assessed at two weeks, one, two, three, and six months or until discharge (mean 3.6 months both groups). Outcomes included: iatrogenic pain following surgery (pillar pain or palmar pain); iatrogenic scar discomfort; paraesthesia or numbness; other clinical signs of CTS (numbness, nocturnal pain, paraesthesia, pain or positive Tinel's sign); and time to return to activities of daily living (ADL) and work.

 

Primary outcomes  

The primary outcome measures were:

1. Long-term change in self reported functional ability as measured on a continuous scale at three months or longer 

  • Alves 2011 did not assess function on a continuous scale and hence no data could be entered into RevMan. However, the trialists reported that all participants in both groups returned to normal ADL.

 

Secondary outcomes  

1. Short-term change in self reported functional ability as measured on a continuous scale at less than three months

2. Change in CTS symptoms as measured on a continuous scale (for example, pain, numbness and paraesthesia)

  • Symptoms including pain, paraesthesia, numbness and clinical signs (Durkan's test, Tinel's sign, Phalen's test) of CTS were reported as dichotomous outcomes at one, two, three, and six months (or on discharge). Average time to discharge for both groups was 3.6 months (intervention group range: one to six months; placebo group range: one to eight months). Results were reported as dichotomous outcomes, analysed in RevMan as RRs ( Analysis 1.1;  Analysis 1.2;  Analysis 1.3;  Analysis 1.4;  Analysis 1.5).
  • There were no statistically significant differences between participants who received low-level laser therapy and the placebo group in numbness or palmar pain at one, two and three months post surgery. Clinical signs in low-level laser and placebo groups at one and two months post surgery were statistically similar (there were no clinical signs in either group at three months) and no nighttime pain in either group at one, two or three months ( Analysis 1.2;  Analysis 1.3;  Analysis 1.4;  Analysis 1.5).
  • Results indicated no statistically significant difference in numbness and paraesthesia at six months post surgery in participants who received low-level laser therapy versus placebo ( Analysis 1.3;  Analysis 1.4). None of the participants in either group displayed clinical signs (Durkan's test, Tinel's sign, Phalen's sign), or nighttime pain at six months post operation ( Analysis 1.5).

3. Change in CTS related impairment measures (for example, grip and pinch strength)

  • Not reported

4. Presence of iatrogenic symptoms secondary to CTR (for example, swelling, scar pain, excessive scarring or pillar pain)

  • Presence of scar pain and pillar pain were reported as dichotomous outcomes (present versus not present) at one, two, three and six months or until participants were discharged. Results indicated that there was no statistical difference between the low level laser therapy group and the placebo group in scar pain and pillar pain at one, two, three and six months post surgery ( Analysis 1.6;  Analysis 1.7).

5. Return to work or occupation (measured as "yes or no") at three months

  • All participants (n = 58) in both groups returned to normal occupations within three months ( Analysis 1.8).

6. Change in neurophysiologic parameters (using nerve conduction studies)

  • Nerve conduction studies were not performed in this study.

7. Presence of adverse events as a result of the rehabilitation

  • No participants required a re-operation as a result of the treatment ( Analysis 1.9).

 

Immobilisation (single intervention) versus bulky dressing (single intervention)

Two randomised trials (Bhatia 2000; Bury 1995) were identified. These trials evaluated the effects of immobilisation using a wrist orthosis compared with bulky dressings allowing limited wrist mobility. However, the duration of the treatment and the outcomes measured were too clinically heterogeneous to pool results.

Bhatia 2000 allocated 130 participants to plaster of Paris splint compared with a bulky dressing applied immediately and worn for 48 hours post surgery. Outcomes assessed were number of pain relief tablets (co-proxamol) taken, and pain intensity measured twice per day for 72 hours post surgery. The trial authors did not report whether any of the participants had bilateral CTR and hence the exact number of wrists included is unknown.

Bury 1995 investigated whether bulky dressing plus wrist orthosis or a bulky wool and crepe dressing alone worn for two weeks post surgery had better outcomes at final follow-up (range 3.8 to 7.8 months). Outcomes assessed were patient-reported outcome, patient-reported satisfaction, frequency of residual or recurrent symptoms and complications, digital and wrist range of motion, grip and pinch strength, and thenar muscle function. Results for some of these outcomes were not reported in the publication and attempts to obtain these data from the trial authors were unsuccessful. Forty-seven participants were randomised and 40 participants (43 wrists) were included for analysis.

 

Primary outcomes  

1. Long-term change in self reported functional ability as measured on a continuous scale at three months or longer

  • Not reported

 

Secondary outcomes  

1. Short-term change in self reported functional ability as measured on a continuous scale at less than three months

  • Not reported

2. Change in CTS clinical symptoms as measured on a continuous scale (for example, pain, numbness and paraesthesia)

  • Pain was measured in Bhatia 2000 using a visual analogue scale (VAS) twice daily for 72 hours after surgery. No numerical data suitable for entry into RevMan 5 were provided. Using the Mann-Whitney U test, the authors reported that there was no statistically significant difference in VAS pain scores between participants wearing a wrist orthosis and those wearing a bulky dressing at two weeks of follow-up.
  • Bury 1995 reported the number of participants who were 'symptom-free' and the number 'improved' or 'cured' versus worse or unchanged. Results were dichotomous and analysed in RevMan as RRs ( Analysis 2.1;  Analysis 2.2). Bury 1995 found no statistically significant benefit from two weeks of immobilisation in a wrist orthosis over a bulky dressing in terms of being symptom free, or being 'improved' or 'cured' rather than 'unchanged' or 'worse' at final follow-up (mean of six months postoperatively) ( Analysis 2.1;  Analysis 2.2).

3. Change in CTS related impairment measures (for example, grip and pinch strength)

  • Reported in Bury 1995 but not measured in Bhatia 2000.
  • Bury 1995 measured grip strength (kg) and lateral pinch strength (kg) at a mean of six months' follow-up, but reported only mean values with no measure of variability; there was no statistically significant difference between groups in either measure.

4. Presence of iatrogenic symptoms secondary to CTR (for example, swelling, scar pain, excessive scarring or pillar pain)

  • Not reported

5. Return to work or occupation ("yes" or "no") at three months

  • Reported in Bury 1995 but not measured in Bhatia 2000.
  • In Bury 1995, seven (27%) participants in the splinted group and two (12%) in the bulky dressing group did not return to work at final follow-up (average 5.7 months); the difference was not statistically significant ( Analysis 2.3).

6. Change in neurophysiologic parameters (using nerve conduction studies)

  • Not reported

7. Presence of adverse events as a results of the rehabilitation

  • Reported in Bury 1995 but not measured in Bhatia 2000.
  • In Bury 1995, the wrist orthosis group reported no adverse effects, whereas one participant in the bulky dressing group had persistent symptoms and underwent revision surgery; this difference between groups was not statistically significant ( Analysis 2.4).

 

Immobilisation (single intervention) versus mobilisation (multiple interventions)

Four trials investigated immobilisation versus mobilisation (Cebesoy 2007; Cook 1995; Finsen 1999; Martins 2006). One quasi-randomised trial (Cebesoy 2007) investigated immobilisation (using a plaster wrist orthosis worn until suture removal) and late mobilisation (bulky dressing worn for a three-week period and immediate early mobilisation exercises). Cook 1995 randomly allocated participants to immobilisation using a volar wrist orthosis for two weeks versus bulky dressing and advice to move the hand and wrist with no restrictions. One quasi-randomised trial (Finsen 1999) compared the use of a plaster wrist orthosis for two weeks versus light dressing and active mobilisation within comfort from 48 hours post surgery. Martins 2006 investigated the efficacy of immobilisation using a neutral wrist orthosis for two weeks post surgery versus no orthosis and unrestricted movement of the wrist and fingers.

Cebesoy 2007, Cook 1995, Finsen 1999 and Martins 2006 examined the effects of immobilisation using a wrist orthosis when compared with mobilisation using active movement of the affected limb commenced immediately postoperatively (Cebesoy 2007) or on the first (Cook 1995) or second (Finsen 1999; Martins 2006) postoperative day. The duration of orthotic use between trials was different: Cebesoy 2007 immobilised the wrists for ten days, Cook 1995 and Martins 2006 immobilised the affected wrists for two weeks, whilst another trial (Finsen 1999) immobilised the affected wrists for four weeks. However, in Finsen 1999 the trialists reported six deviations from protocol in which people were splinted for either a shorter or longer time.

 

Primary outcomes  

1. Long-term change in self reported functional ability as measured on a continuous scale at three months or longer

  • Reported in Cebesoy 2007
  • Function was assessed using the Functional Severity Scale on the BCTQ preoperatively and three months post surgery in Cebesoy 2007. There was no statistically significant difference in function between participants receiving bulky dressing and early mobilisation compared to those receiving splint and late mobilisation at three months post surgery ( Analysis 3.1).

 

Secondary outcomes  

1. Short-term change in self reported functional ability as measured on a continuous scale at less than three months

  • Reported in Cebesoy 2007 and Cook 1995.
  • At one month post surgery in Cebesoy 2007, there was no statistically significant difference in improvement in function (using the BCTQ Functional Severity Scale) between participants receiving bulky dressing and early mobilisation and those receiving orthosis and late mobilisation ( Analysis 3.2).

  • Cook 1995 included the time that participants reported return to normal functional activities of daily living on a continuous scale (from date of surgery to date of activity resumption). No measures of variability were reported so data could not be entered into RevMan for analysis. However, using a two sample t-test, the trialists reported that the dressing plus early mobilisation group had a more rapid return to activities (mean six days in the non-splinted group versus 12 days in the splinted group; P = 0.0004).

2. Change in CTS clinical symptoms as measured on a continuous scale (for example, pain, numbness and paraesthesia)

CTS symptom severity

  • In Cebesoy 2007, symptoms of CTS were assessed using the BCTQ Symptom Severity Scale preoperatively, and at one and three months post surgery. There was no statistically significant difference in symptom scores between splint and late mobilisation groups at one or three months ( Analysis 3.3).
  • In Martins 2006, change on the BCTQ Symptom Severity Scale and Symptom Intensity Score were measured at the end of two weeks' treatment, and were reported as end point mean ± standard deviation (SD) scores and as index mean ± SD scores (calculated as pre-operative value - postoperative value / pre-operative value). At the end of two weeks' treatment, no statistically significant difference was found on the BCTQ Symptom Severity Score or the Symptom Intensity Score. Nor was there a statistically significant difference at two weeks in change from pre-operative scores for the Symptom Severity Score or Symptom Intensity Score ( Analysis 3.3,  Analysis 3.4; Analysis 3.5).

CTS pain severity using a VAS

  • Cook 1995 assessed pain severity using a VAS (1 to 10) at the end of two weeks of treatment, and at both two and 10 weeks after cessation of treatment. However, the trial authors reported no measures of variability, which precluded entry of data into RevMan. According to the authors, using an independent samples t-test, "Average subjective pain rating on a ten point scale was significantly better for the unsplinted patients 14 days after surgery (0.9 for unsplinted vs 2.4 for splinted, P = 0.001) and 1 month after surgery (0.5 for unsplinted vs 1.5 for splinted, P=0.01). Subjective rating and pain rating did not differ between the two groups 3 and 6 months after surgery."
  • CTS pain severity (0 to 100 scale) was also assessed in Finsen 1999 at two and six weeks and six months post surgery. However, the authors reported median values and CIs that were reflective of skewed data (hence not appropriate for inclusion in a standard meta-analysis). According to the authors, based on results from non-parametric statistical tests, the VAS pain values were not significantly different between the immobilised and mobilised groups at any time point post surgery.

3. Change in CTS related impairment measures (for example, grip and pinch strength)

  • Reported in Cook 1995 and Finsen 1999
  • Grip strength and key pinch strength were measured in Cook 1995 at the end of two weeks of treatment, and at two and 10 weeks after treatment ceased. Measures of variability (for example, SDs) were not reported by the authors, and attempts to obtain them were unsuccessful. According to the authors, based on an independent samples t-test, "Grip strength was slightly greater in unsplinted patients at 14 days after surgery (15 kg in unsplinted vs 10 kg in splinted, P = 0.003) and at 1 month (18 kg in unsplinted vs 14 kg in splinted, P = 0.02). By 3 months grip strength was equivalent in the two groups. Similarly, key pinch strength recovered more rapidly in the unsplinted hands at 14 days (6 kg vs 4 kg, p = 0.01) and 1 month (7 kg vs 5 kg, P=0.01), but did not differ by 3 months".
  • Finsen 1999 assessed impairment using measures of grip strength, key pinch strength, and pinch strength between the thumb and fourth and fifth fingers (4/5-pinch). However, median values and 95% CIs were reported and attempts to obtain data suitable for inclusion in RevMan 5 were unsuccessful. Based on non-parametric tests, the authors reported that "There was a considerable loss of strength in the operated hand, compared to preoperative values at 6 weeks for all three parameters. The reductions in grip and key pinch strength were almost identical in the two treatment groups" and "4/5 pinch strength was also significantly reduced in both groups at 6 weeks."

  • Impairment was assessed using grip strength and key pinch strength in Cook 1995 at six months after treatment cessation. No numerical data were reported by the authors, and attempts to obtain these data were unsuccessful. By applying an two samples t-test, the only information on these outcomes reported by the authors was that "...by 6 months grip strength in both groups slightly exceeded preoperative grip strength....".
  • Grip strength, key pinch strength, and pinch strength between the thumb and fourth and fifth fingers (4/5-pinch) was also measured in Finsen 1999 at six months post surgery, but the data reported were not in a format suitable for entry into RevMan 5. According to the authors, "At 6 months, the grip strength had returned to preoperative values in both groups and the key pinch strength had improved considerably. Again, the values in the two groups were almost the same...It [4/5 pinch strength] had improved after 6 months, but was still around 20% lower than preoperatively. Patients in the immobilised group were slightly weaker than the others, but the difference was not statistically significant."

  • Two-point discrimination and touch sensation determined by Semmes-Weinstein monofilaments was measured in Cook 1995 at the end of two weeks of treatment, and at two and 10 weeks after treatment ceased. Measures of variability were not reported by the authors, and attempts to obtain data were unsuccessful. According to the authors, based on an independent samples t-test, "Improvement in two-point discrimination and sensibility measured using Semmes-Weinstein monofilaments was similar in the two groups of patients. "At the end of two weeks of treatment, touch sensation was measured using two-point discrimination in Martins 2006. There was a significant difference between the end point scores of the immobilisation and mobilisation groups. However, the difference between the change scores at two weeks post operation was not statistically significant ( Analysis 3.6; Analysis 3.7).

4. Presence of iatrogenic symptoms secondary to CTR (for example, swelling, scar pain, excessive scarring or pillar pain)

  • Finsen 1999, Cook 1995 and Martins 2006 reported the presence of iatrogenic complications as a result of the CTR surgery. Cook 1995 reported that no wound complications or bowstringing of tendons were observed in either group. Further, there was no statistically significant difference between the orthosis and mobilisation (using range-of-motion exercises) groups in the incidence of scar tenderness or pillar pain at one month. No statistically significant difference was found in Finsen 1999 between the wrist immobilisation and mobilisation groups in frequency of scar discomfort pain, hypothenar pain or thenar pain at six weeks and at six months. Martins 2006 reported that no median nerve lesion, wound dehiscence or tendon injuries were experienced in either group. For all analyses, see  Analysis 3.8.

5. Return to work or occupation (measured as 'yes' or 'no') at three months

  • Reported in Cook 1995 and Finsen 1999.
  • Cook 1995 reported the mean number of days until return to activities of daily living, to light duty work, and to full duty work. However, no measures of variability were reported. Using an independent samples t-test, the authors reported that "Unsplinted patients had a more rapid return to activities of daily living (average six days in unsplinted, 12 days in splinted, P=0.0004); more rapid return to light duty work (15 days in unsplinted, 24 days in splinted, P=0.01); and more rapid return to full duty work (17 days in unsplinted, 27 days in splinted, P= 0.005)."
  • Finsen 1999 reported the number of weeks sicklisted by participants in each group who had been gainfully employed before CTR. The authors reported median values and CIs that were reflective of skewed data (not appropriate for inclusion in a standard meta-analysis). The gainfully employed participants in both the mobilisation group and the immobilised group were sicklisted for a median of six weeks postoperatively (95% CI 5 to 6 weeks and 4 to 7 weeks, respectively).

6. Change in neurophysiologic parameters (using nerve conduction studies)

  • Not reported

7. Presence of adverse events as a results of the rehabilitation

  • In Cebesoy 2007, 16 of 20 participants (80%) in the splinted group reported a heavy feeling and discomfort caused by the intervention, whereas none of the participants in the bulky dressing group reported this problem ( Analysis 3.9). No flexor bowstringing was reported in either group.
  • Cook 1995, Finsen 1999 and Martins 2006 reported complications (iatrogenic symptoms) as a result of the carpal tunnel surgery rather than complications as a result of the rehabilitation intervention.

 

Elevation (single intervention) versus standard care (control)

Fagan 2004 examined the benefit of elevation using a home elevation device with a Bradford sling suspended vertically at night and a crepe sling when ambulant for five days post surgery, compared with a control group (standard care), in 43 participants. Outcomes included hand volume using a volume displacement apparatus (assessed pre-operatively and at five days post surgery), pain (assessed once a day for five days post surgery) and analgesic usage each day (for five days).

 

Primary outcomes  

1. Long-term change in self reported functional ability as measured on a continuous scale at three months or longer 

  • Not reported

 

Secondary outcomes

1. Short-term change in self reported functional ability as measured on a continuous scale at less than three months

  • Pain was assessed using a VAS (0 to 10 scale) at five days post surgery. There was no statistically significant difference in this outcome between participants using a home elevation device and Bradford sling and those receiving standard care ( Analysis 4.1).

2. Change in CTS clinical symptoms as measured on a continuous scale (for example, pain, numbness and paraesthesia)

  • Not reported

3. Change in CTS related impairment measures (for example, grip and pinch strength)

  • Not reported

4. Presence of iatrogenic symptoms secondary to CTR (for example, swelling, scar pain, excessive scarring and pillar pain)

  • Swelling (volume) was assessed pre-operatively and at five days post surgery using a volume displacement apparatus. There was no statistically significant difference in swelling between the home elevation device and standard care ( Analysis 4.2).

5. Return to work or occupation (measured as 'yes' or 'no') at three months

  • Not reported

6. Short-term (less than three months) and long-term (three months or more) change in neurophysiologic parameters (using nerve conduction studies)

  • Not reported

7. Presence of adverse events as a results of the rehabilitation at short-term (less than three months) and long-term (three months or more) follow-up 

  • Not reported

 

Electrical stimulation (single intervention) versus no treatment (control)

A trial by Gordon 2010 compared the use of electrical stimulation of the median nerve 30 minutes after CTR for one hour with a no treatment control group. Twenty-five participants (25 wrists) were allocated to either the intervention or control group. Outcomes included results of nerve conduction studies, BCTQ (Symptom Severity Score and Functional Status Scores) and hand touch sensation using Semmes-Weinstein monofilaments. They were assessed twice pre-operatively, and at three, six to eight and 12 months post surgery.

 

Primary outcomes  

1. Long-term change in self reported functional ability as measured on a continuous scale at three months or greater 

  • In Gordon 2010, the BCTQ Functional Status Score was used to measure functional ability at three, six to eight, and 12 months post-surgery. Statistics were reported graphically, and attempts to obtain numerical data from the trial authors were unsuccessful.

 

Secondary outcomes  

1. Short-term change in self reported functional ability as measured on a continuous scale at less than three months

  • Not reported

2. Change in CTS clinical symptoms as measured on a continuous scale (for example, pain, numbness and paraesthesia)

  • BCTQ (Symptom Severity Score) was used to measure functional ability at three, six to eight, and 12 months post surgery. Statistics were reported graphically, and attempts to obtain numerical data from the trial authors were unsuccessful.

3. Change in CTS related impairment measures (for example, grip and pinch strength)

  • Impairment in touch sensation was measured using Semmes Weinstien Monofilaments at three, six to eight, and 12 months post-surgery. Statistics were reported graphically and attempts to obtain numerical data from the trial authors were unsuccessful.

4. Presence of iatrogenic symptoms secondary to CTR (for example, swelling, scar pain, excessive scarring and pillar pain)

  • Not reported

5. Return to work or occupation (measured as 'yes' or 'no') at 3 months

  • Not reported

6. Change in neurophysiologic parameters (using nerve conduction studies)

  • Nerve conduction (using motor terminal latency and sensory terminal latency) was measured at baseline (pre-operatively) and at three months post surgery. The authors stated that, "the latency did not change significantly in the control group in the postoperative period, while in contrast, significant acceleration in the motor latency occurred early in the stimulation group at 3 months. Motor latencies from 3 months onwards were the same as that for the healthy subjects. Simlarly, early recovery of conduction velocity of the sensory nerve fibres was found in the stimulation group at 3 months when amplitude of the SNAP had not yet changed significantly from pre-operative values. In contrast recovery was delayed in the control patient group."

7. Presence of adverse events as a results of the rehabilitation

  • Not reported.

 

Controlled cold therapy and narcotic use (multiple interventions) versus ice therapy plus narcotic use (multiple interventions)

One randomised trial (Hochberg 2001) was identified. It compared controlled cold therapy (plus narcotic usage) with ice therapy (plus narcotic usage). Controlled cold therapy was applied using a thermostatically controlled cooling blanket maintained at 7.2°C continuously for 12 hours per day for three days post surgery. Ice therapy was applied using a commercially available ice pack applied immediately after surgery and on return home use of a ice bag (ice cubes in a plastic bag) for 12 hours per day for three days post surgery. Participants in both groups were provided with 28 combined hydrocodone and paracetamol pain relief tablets. Seventy-two participants (72 wrists) were randomly allocated to either of the intervention groups. Outcomes were measured pre-operatively, immediately post surgery and three days post surgery, and included swelling measured at the wrist by circumference and pain intensity.

 

Primary outcomes

1. Long-term change in self reported functional ability as measured on a continuous scale at three months or longer 

  • Not reported

 

Secondary outcomes  

1. Short-term change in self reported functional ability as measured on a continuous scale at less than three months

  • Not reported.

2. Change in CTS clinical symptoms as measured on a continuous scale (for example, pain, numbness and paraesthesia)

  • Intensity of pain severity (measured using a 0 to 10 VAS) was measured before CTR and at the end of three days' treatment. End point and change scores were reported based on a per protocol analysis and an intention-to-treat analysis. At the end of three days' treatment, participants receiving controlled cold therapy were found to have statistically significantly less pain than those receiving ice therapy as based on a per protocol analysis (MD -2.80; 95% CI -4.50 to -1.10) and an intention-to-treat analysis (MD -1.90; 95% CI -3.51 to -0.29). However, while the controlled cold therapy group had a statistically significantly greater reduction in pain from baseline to day three on a per protocol analysis (MD -2.80; 95% CI -4.88 to -0.72), no statistically significant change in pain between groups was found using an intention-to-treat analysis (MD -1.40; 95% CI -3.24 to 0.44) ( Analysis 5.1).

3. Change in CTS related impairment measures (for example, grip and pinch strength)

  • Not reported.

4. Presence of iatrogenic symptoms secondary to CTR surgery (for example, swelling, scar pain, excessive scarring, and pillar pain)

  • Swelling was recorded using wrist circumference measurements immediately postoperatively and at three days post surgery. Both endpoint and change scores were reported based on a per protocol analysis and an intention-to-treat analysis. At the end of three days' treatment, there was no statistically significant difference in the amount of swelling (endpoint score) between controlled cold therapy and ice therapy groups based on per protocol analysis or intention-to-treat analysis. However, when measured as change scores, the controlled cold therapy group had a statistically significant greater reduction from baseline to day three compared to ice therapy, on per protocol (MD -1.00; 95% CI -1.26 to -0.74) and intention-to-treat analyses (MD -1.10; 95% CI -1.33 to -0.87) (  Analysis 5.2).
  • We have assumed that the mean change from baseline to day three in oedema (wrist circumference) in the "ice therapy group" was incorrectly reported by the trial authors. In both cases the value reported is -0.7, but the end point scores suggest that these values should be +0.7, as wrist circumference increased in the ice therapy group. Further, the authors report that: "At 3 days, of the 24 CCT [controlled cold therapy] patients, 19 showed reduction in mean wrist circumference from baseline, three showed no change and two showed an increase. In contrast, all patients in the ice therapy group showed an increase in mean wrist circumference at 3 days. When all patients for whom edema scores were available were included in an intention-to-treat analysis, the CCT group again showed a statistically significant greater reduction in wrist circumference from baseline and significantly greater mean percentage reduction in wrist circumference than the ice-therapy group." Attempts to contact the authors to confirm this have been unsuccessful.

5. Return to work or occupation (measured as 'yes' or 'no') at three months

  • Not reported.

6. Change in neurophysiologic parameters (using nerve conduction studies)

  • Not reported.

7. Presence of adverse events as a results of the rehabilitation

  • Not reported.

 

Bulky dressing and splint (single intervention) versus light dressing (single intervention)

One trial by Huemer 2007 allocated 50 participants (50 wrists) to either a bulky dressing with a volar wrist orthosis in a neutral position for 48 hours post surgery or a light bandage dressing worn for 48 hours post surgery. Outcomes were measured pre-operatively and at three months post surgery and included: pain intensity, two-point discrimination, grip strength, results of nerve conduction studies and scar tenderness.

 

Primary outcome

1. Long-term change in self reported functional ability as measured on a continuous scale at three months or longer 

  • Not reported.

 

Secondary outcomes  

1. Short-term change in self reported functional ability as measured on a continuous scale at less than three months

  • Not reported.

2. Change in CTS clinical symptoms as measured on a continuous scale (for example, pain, numbness and paraesthesia)

  • Pain (VAS 0 to 10) was assessed in Huemer 2007 at the end of two days treatment; however, no measure of variability was reported, so data could not be entered into RevMan. No statistically significant difference between participants wearing a wrist splint and those wearing a light dressing for 48 hours post CTR was reported.

3. Change in CTS related impairment measures (for example, grip and pinch strength)

  • In Huemer 2007, CTS related impairment was assessed using measures of grip strength (kg) at three months post surgery. Only mean values were reported (no measures of variability available).The authors reported no statistically significant difference.
  • Two-point discrimination was used to measure hand numbness. However, no measurement of variability was reported so data could not be entered into RevMan.

4. Presence of iatrogenic symptoms secondary to CTR (for example, swelling, scar pain, excessive scarring, and pillar pain)

  • Participants in Huemer 2007 were asked to report whether they had no perceptible scar pain, scar pain with pressure or scar pain at rest at three months of follow-up. There was no statistically significant difference between immobilisation and light dressing groups in the number of participants who reported having no perceptible scar pain at three months ( Analysis 6.1).

5. Return to work or occupation (measured as 'yes' or 'no') at three months

  • Not reported.

6. Change in neurophysiologic parameters (using nerve conduction studies)

  • Distal motor latency (msec) was reported in Huemer 2007 as mean improvement from baseline to three months of follow-up. However, only mean values were given, so no data could be entered into RevMan 5.1. The authors reported no statistically significant difference between the splint and light dressing groups.

7. Presence of adverse events as a result of the rehabilitation

  • Huemer 2007 reported that there were no median nerve, digital nerve, vascular, or tendon complications in either group, and delayed wound healing was not observed.

 

Contrast baths plus exercise (multiple interventions) versus contrast baths (single intervention) versus exercise (single intervention)

One randomised trial (Janssen 2009) allocated 58 participants to either contrast baths alone or contrast baths plus exercise or exercise only for the treatment of postoperative oedema in the immediate period following CTR. Outcomes were measured immediately after treatment delivered 10 to 14 days post surgery, and included hand volume using the water displacement method.

 

Primary outcomes  

1. Long-term change in self reported functional ability as measured on a continuous scale at three months or longer 

  • Not reported.

 

Secondary outcomes  

1. Short-term change in self reported functional ability as measured on a continuous scale at less than three months

  • Not reported.

2. Change in CTS clinical symptoms as measured on a continuous scale (for example, pain, numbness and paraesthesia)

  • Not reported.

3. Change in CTS related impairment measures (for example, grip and pinch strength)

  • Not reported.

4. Presence of iatrogenic symptoms secondary to CTR (for example, swelling, scar pain, excessive scarring, and pillar pain)

  • Oedema (measured as the change in hand volume in mL) was measured before and after the intervention at 10 to 14 days post surgery. Janssen 2009 found no statistically significant difference in swelling between participants receiving contrast baths plus exercises and those receiving contrast baths alone. There was more swelling with contrast baths plus exercises than with exercises alone (MD 23.20; 95% CI 3.60 to 42.80) and more swelling with contrast baths alone than with exercises alone (MD 32.00; 95% CI 12.61 to 51.39) ( Analysis 7.1;  Analysis 8.1;  Analysis 9.1).

5. Return to work or occupation (measured as 'yes' or 'no') at three months

  • Not reported.

6. Change in neurophysiologic parameters (using nerve conduction studies)

  • Not reported.

7. Presence of adverse events as a results of the rehabilitation

  • Not reported.

 

Arnica (single intervention) versus "sham" therapy (placebo)

One randomised trial (Jeffrey 2002) examined the efficacy of arnica D6 tablets and ointment used postoperatively for swelling and bruising. Forty participants (80 wrists) were allocated to either the intervention group or a placebo group. They were advised to take the tablets three times daily for two weeks and commence massage of the ointments around the wound at 72 hours post surgery until two weeks post surgery. Outcomes were measured pre-operatively and at one and two weeks post surgery. Outcomes included grip strength, wrist circumference, pain intensity, and adverse events such as allergy or infection.

 

Primary outcomes  

1. Long-term change in self reported functional ability as measured on a continuous scale at three months or longer 

  • Not reported.

 

Secondary outcomes  

1. Short-term change in self reported functional ability as measured on a continuous scale at less than 3 months

  • Not reported.

2. Change in CTS clinical symptoms as measured on a continuous scale (for example, pain, numbness and paraesthesia)

  • Pain intensity during the postoperative period was measured using a VAS (which was converted into a 0 to 10 scale) at the end of one and two weeks' treatment. However, only the mean values were reported numerically (SDs were presented graphically, but could not be extracted using Microsoft Paint). Using Student's t-test or the Mann-Whitney U test, the authors reported that "At 1 week, the Arnica group had a mean hand-discomfort score of 2.6 compared to 3.5 for the placebo group; this was not significantly different. At 2 weeks, the Arnica group had a mean hand-discomfort score of 1.3 compared to 2.5 for the placebo group, which was statistically significant (P<0.03)."

3. Change in CTS related impairment measures (for example, grip and pinch strength)

  • Grip strength (kg) was measured in Jeffrey 2002. No statistically significant difference in percentage change from preoperative values was found between participants receiving arnica D6 tablets and ointment and those receiving placebo at the end of one and two weeks of treatment ( Analysis 10.1).

4. Presence of iatrogenic symptoms secondary to CTR (for example, swelling, scar pain, excessive scarring, and pillar pain)

  • Jeffrey 2002 found no statistically significant difference between arnica D6 tablets and ointment and placebo in terms of percentage change from pre-operative value in hand swelling (wrist circumference) at the end of one week and two weeks' of treatment ( Analysis 10.2).

5. Return to work or occupation (measured as 'yes' or 'no') at three months

  • Not reported.

6. Change in neurophysiologic parameters (using nerve conduction studies)

  • Not reported.

7. Presence of adverse events as a results of the rehabilitation

  • In Jeffrey 2002, no adverse effects (such as allergy or infection) were reported in the arnica or placebo groups.

 

High dose arnica (single intervention) versus low dose arnica (single intervention) versus "sham" therapy (placebo)

Stevinson 2003 randomly allocated 64 participants to either high dose (30C) arnica tablets or low dose (6C) arnica tablets or placebo. Arnica was taken three times per day for seven days pre-operatively and 14 days postoperatively. The placebo tablets were identical in appearance to the arnica tablets. Outcomes included pain using the short-form McGill Pain Questionnaire (MPQ), bruising measurement using colour analysis from a photograph of the participants' hands, clinician-rated bruising, swelling measured by wrist circumference, use of analgesic medication, and adverse events.

 

Primary outcomes  

1. Change in self reported functional ability as measured on a continuous scale at three months or longer 

  • Not reported.

 

Secondary outcomes  

1. Change in self reported functional ability as measured on a continuous scale at less than three months

  • Not reported.

2. Change in CTS clinical symptoms as measured on a continuous scale (for example, pain, numbness and paraesthesia)

  • Pain was assessed using the MPQ (0 to 100 VAS) and by asking participants to rate whether they experience different pain descriptor words such as 'stabbing, 'gnawing' and 'shooting'. However, the data for these continuous measures could not be entered into RevMan 5 as only median (range) values were reported. Using Chi2 tests, the authors only reported that "Postoperative pain did not differ between the groups at day 4 according to VAS scores..." . It was also reported that "The only group difference that approached statistical significance was on the MPQ descriptors total score (Chi2=6.72, d.f. = 2, P = 0.04) where the placebo group had lower scores than the arnica 30C group at day nine (U = 122.0, P = 0.01, Mann–Whitney U test)."

3. Short-term (less than three months) and long-term (three months or more) change in CTS related impairment measures (for example, grip and pinch strength)

  • Not reported.

4. Presence of iatrogenic symptoms secondary to CTR surgery (for example, swelling, scar pain, excessive scarring and pillar pain)

  • Stevinson 2003 reported the number of participants who were rated by a clinician as having no, mild to moderate, or severe bruising after 4, 9 and 14 days treatment. We dichotomised participants into those who were rated as having 'no bruising' and those who were rated as having mild to moderate or severe bruising. There was no statistically significant difference in the number of participants rated as having no bruising between arnica 30C and placebo, arnica 6C and placebo or between the two doses of arnica, at any of the three time points ( Analysis 11.1;  Analysis 12.1; Analysis 13.1). Stevinson 2003 also assessed the extent of bruising (by taking a photograph of participants' wrists and analysing the blue and red channel brightness). Similarly, bruising did not differ between the groups at day four in terms of blue or red channel brightness.

5. Return to work or occupation (measured as 'yes' or 'no') at three months

  • Not reported.

6. Change in neurophysiologic parameters (using nerve conduction studies)

  • Not reported.

7. Presence of adverse events as a results of the rehabilitation

  • In Stevinson 2003, eight participants reported adverse effects: three in the placebo group (heartburn; sore throat and flu-like symptoms; faintness and headache), three in the arnica 30C group (dry mouth; headache; feeling ‘throbby’ in head/neck), and two in the arnica 6C group (drowsiness; sore tongue). The differences between groups (arnica 30C versus placebo, arnica 6C versus placebo and arnica 30C versus arnica 6C) were not statistically significant ( Analysis 11.2;  Analysis 12.2;  Analysis 13.2).

 

Electrical stimulation versus decimer wave therapy versus combined therapy versus control

The study conducted by Li 2008 involved three different treatment groups and a no-treatment control group to examine the benefit of decimeter wave therapy and electrical stimulation on recovery of nerve function following peripheral nerve entrapment surgery. Each treatment group was treated for 20 days, followed by a 10 day break, for three months. The first intervention group was given once daily electrical stimulation, six min per session and the second group, daily decimeter wave therapy using a mild-hot therapeutic instrument applied in the early stages at 10 to 15 W for 10 min per session, increased to 10 to 30 W in the middle-late phase of treatment for 20 min per session. The third group received compound physical factor treatment (electrical stimulation and decimeter wave therapy combined). A total of 124 participants with peripheral nerve entrapment were allocated to the four groups; 75 of them had CTS. Trial authors did not report CTS specific data and attempts to obtain this information were unsuccessful. Therefore, we were unable to analyse outcome data in this review.

 

Multimodal hand therapy (multiple interventions) versus no formal therapy (control)

Pomerance 2007 examined the effects of a formal program of multimodal hand therapy (consisting of six 30 min sessions of nerve gliding, range of motion and strengthening and additional treatments, for example, massage, fluidotherapy with a qualified hand therapist). Treatments were provided over a two-week period starting at five to seven days post surgery. The control group received advice regarding tendon gliding exercises and scar massage prior to surgery but no formal therapy after surgery. A total of 150 participants were randomised. Outcomes included time to return to work, pain intensity, lateral pinch strength, grip strength, function using the DASH questionnaire, persistence of symptoms, wound dehiscence, and an economic evaluation of the intervention.

 

Primary outcomes  

1. Long-term change in self reported functional ability as measured on a continuous scale at three months or longer 

  • DASH was measured at five and a half months post-treatment (six months post surgery). There was no statistically significant difference between treatments ( Analysis 14.1).

 

Secondary outcomes  

1. Short-term change in self reported functional ability as measured on a continuous scale at less than three months

  • Not reported.

2. Change in CTS clinical symptoms as measured on a continuous scale (for example, pain, numbness and paraesthesia)

  • Change in CTS clinical symptoms was measured in Pomerance 2007 using a VAS (0 to 10) to assess CTS pain at the end of two weeks of treatment, and at two, four, and 10 weeks and five and a half months after treatment ended ( two, four, six, and 12 weeks and six months post surgery). However, no numerical data were reported for this outcome, and the authors only reported that by applying Student's t-test, no statistically significant difference was found in pain complaints at any time point post surgery between the multimodal hand therapy and the no therapy groups.

3. Change in CTS related impairment measures (for example, grip and pinch strength)

  • Grip strength (kg) and lateral pinch strength (kg) were measured in Pomerance 2007. The change in grip strength was not statistically significantly different in the multimodal hand therapy group compared to controls at any time point ( Analysis 14.2). Nor was multimodal hand therapy found to improve lateral pinch strength compared to controls ( Analysis 14.3).

4. Presence of iatrogenic symptoms secondary to CTR (for example, swelling, scar pain, excessive scarring, and pillar pain)

  • Not reported.

5. Return to work or occupation (measured as 'yes' or 'no') at three months

  • The number of participants in each group who returned to regular-duty work at certain time points was recorded by Pomerance 2007. Data were reported separately for cases with Medicare insurance, commercial insurance, or workers' compensation insurance, but these data were combined for entry into RevMan. There was no statistically significant difference between multimodal hand therapy and no formal therapy in terms of the number of participants in each group who had returned to work by two weeks post surgery, but at six weeks post surgery (RR 1.02; 95% CI 0.89 to 1.17), and eight weeks post surgery (RR 1.04; 95% CI 0.97 to 1.12) results favoured the therapy group. It was reported that all participants in this trial had returned to regular-duty work by 12 weeks following CTR ( Analysis 14.4).

6. Change in neurophysiologic parameters (using nerve conduction studies)

  • Not reported.

7. Presence of adverse events as a results of the rehabilitation

  • Pomerance 2007 reported that there were three adverse effects throughout the study period: one in the multimodal hand therapy group and two in the no therapy control group, with no statistically significant difference between groups . These participants experienced a wound dehiscence when sutures were removed five days postoperatively ( Analysis 14.5).

 

Desensitisation therapy (as part of multiple interventions) versus standard treatment (control)

The Powell 2003 unpublished study randomly allocated 29 participants to either a graduated desensitisation program for three months or a standard treatment control. Outcomes were measured at three and six weeks, and three months post operation. Outcomes included scar sensitivity using a dolorimeter (pressure gauge), patient-reported scar sensitivity, functional status using the BCTQ Functional Status Scale, and grip strength.

 

Primary outcomes  

1. Long-term change in self reported functional ability as measured on a continuous scale at three months or longer

  • BCTQ Functional Status Scale was used to record functional ability at three months. There was no statistically significant benefit of graded desensitisation over standard treatment ( Analysis 15.1)

 

Secondary outcomes  

1. Short-term change in self reported functional ability as measured on a continuous scale at less than three months

  • BCTQ Functional Status Scale was used to measure self reported functional ability at three and six weeks. No statistically significant difference was found between the intervention and control group at three or six weeks postoperatively ( Analysis 15.2).

2. Change in CTS clinical symptoms as measured on a continuous scale (for example, pain, numbness and paraesthesia)

  • Discomfort was measured using a 0 to 100 VAS. No statistically significant difference was found between the intervention and control group at three, six and 12 weeks postoperatively ( Analysis 15.3).

3. Change in CTS related impairment measures (for example, grip and pinch strength)

  • Impairment was assessed using grip strength. No statistically significant differences were found between groups at three, six and 12 weeks postoperatively ( Analysis 15.4).

4. Presence of iatrogenic symptoms secondary to CTR (for example, swelling, scar pain, excessive scarring and pillar pain)

  • Iatrogenic symptoms including scar sensitivity using an objective dolorimeter pressure gauge. There were no statistically significant differences found between groups at three, six and 12 weeks postoperatively ( Analysis 15.5).

5. Return to work or occupation (measured as 'yes' or 'no') at three months

  • Not reported.

6. Change in neurophysiologic parameters (using nerve conduction studies)

  • Not reported.

7. Presence of adverse events as a results of the rehabilitation

  • No adverse events were recorded in either the intervention of control group with respect to wound dehiscence.

 

Multimodal therapy (multiple interventions) versus progressive patient-directed home exercise program (single intervention)

Provinciali 2000 examined the benefits of multimodal formal therapy program (10 one-hour sessions of physiotherapy including soft tissue mobilisation, exercises, scar massage, nerve gliding, grip and pinch exercises, motor dexterity exercises, sensory stimulation and sensory re-education by the same physiotherapist), compared with a progressive patient-directed home exercise program. Outcomes included hand dexterity using the nine-hole peg test, hand function using the Jebsen-Taylor test, BCTQ Symptom Severity Scale, and time to return to work for workers' compensation participants. One hundred participants were allocated to each group; however, some participants were reported to have had bilateral surgeries.

 

Primary outcomes  

1. Long-term change in self reported functional ability as measured on a continuous scale at three months or longer 

  • Not reported.

 

Secondary outcomes  

1. Short-term change in self reported functional ability as measured on a continuous scale at less than three months

  • Not reported.

2. Change in CTS clinical symptoms as measured on a continuous scale (for example, pain, numbness and paraesthesia)

  • Symptom severity was assessed in Provinciali 2000 using the Italian version of the BCTQ at the end of two weeks of treatment (one month post surgery) and two months later. The authors only reported the summed scores across participants for items 1 to 10 (with no measures of variability). Therefore, these data could not be entered into RevMan 5 for statistical analysis. Using a Chi2 test, and applying the Bonferroni correction which resulted in the criterion for statistical significance being set at P < 0.001, the authors reported that no significant difference in occurrence of CTS symptoms was found between the multimodal hand therapy group and the home exercises group at either time point.

3. Change in CTS related impairment measures (for example, grip and pinch strength)

  • Not reported.

4. Presence of iatrogenic symptoms secondary to CTR surgery (for example, swelling, scar pain, excessive scarring and pillar pain)

  • Not reported.

5. Return to work or occupation (measured as 'yes' or 'no') at three months

  • Provinciali 2000 measured the mean number of days until participants returned to work. However, workers' compensation cases were excluded, but the report does not state the number excluded for this reason from this outcome analysis or the proportion of participants returning to work in each group. Therefore, these data could not be entered into RevMan for analysis.

6. Change in neurophysiologic parameters (using nerve conduction studies)

  • Not reported.

7. Presence of adverse events as a results of the rehabilitation

  • Not reported.

 

Short duration postoperative dressing (single intervention) versus extended duration postoperative dressing (single intervention)

Two trials (Ritting 2012; Williams 2008) investigated the effect of short versus extended duration postoperative dressing. In the study conducted by Ritting 2012, 94 participants were allocated to either a postoperative bulky dressing worn for 48 to 72 hours or for nine to 14 days. Outcomes were measured at two and six to 12 weeks post surgery and included: BCTQ, grip strength, tip pinch strength, three-point pinch strength, lateral pinch strength and wound healing. Williams 2008 compared outcomes between a bulky dressing applied for 24 hours to one applied for two weeks post surgery, in a study that included 100 participants. Outcomes were assessed pre-operatively and at the end of the intervention (two weeks) and included BCTQ and change in iatrogenic symptoms.

1. Long-term change in self reported functional ability as measured on a continuous scale at three months or longer 

  • Measured in Ritting 2012 but not in Williams 2008.
  • Ritting 2012 measured the overall results of the BCTQ (Symptom Severity Score and Functional Status Score reported as a combined score) at six to 12 weeks. As the functional status score was not reported separately, no data could be entered into Revman for this outcome.

 

Secondary outcomes  

1. Short-term change in self reported functional ability as measured on a continuous scale at less than three months

  • Measured in Williams 2008 but not in Ritting 2012.
  • Williams 2008 analysed BCTQ Functional Status Scores and found no statistically significant difference in the endpoint scores at two weeks), but the change from baseline score favoured the extended duration dressing (MD 0.40; 95% CI 0.05 to 0.75) ( Analysis 16.1).
  • Ritting 2012 reported an overall BCTQ and Functional Status Score but results were not available for analysis.

2. Change in CTS clinical symptoms as measured on a continuous scale (for example, pain, numbness and paraesthesia)

  • Measured in Williams 2008 but not measured in Ritting 2012.
  • Williams 2008 analysed the Symptom Severity Scores from the BCTQ and found no statistically significant differences between groups at end point (two weeks). However, a statistically significant difference was found in the change scores (baseline to two weeks) (MD 0.30; 95% CI 0.01 to 0.59) ( Analysis 16.2), favouring the extended duration dressing.
  • Ritting 2012 reported an overall BCTQ and the results of the Symptom Severity Score subscale were not available for further analysis.

3. Change in CTS related impairment measures (using grip and pinch strength)

  • Measured in Ritting 2012 but not in Williams 2008.
  • Ritting 2012 examined the differences in grip strength, pinch strength (tip pinch, three-point pinch and lateral pinch) between groups at two weeks and six to 12 weeks post surgery. Grip strength was statistically significantly better in the group who had their postoperative dressing removed earlier (MD -16.00; 95% CI -21.57 to -10.43;  Analysis 16.3). There were no statistically significant differences in three-point pinch or lateral pinch but a small statistically significant difference favouring the short dressing group was found for tip pinch (MD -1.20; 95% CI -2.35 to -0.05) ( Analysis 16.4).

4. Presence of iatrogenic symptoms secondary to CTR surgery (for example, swelling, scar pain, excessive scarring and pillar pain)

  • Measured in both Ritting 2012 and Williams 2008.
  • Wound healing using a qualitative assessment describing the status of the wound (pristine, erythema, dehiscence or drainage) was reported in Ritting 2012. There were no complications reported in either group at the final postoperative evaluation in Ritting 2012. One participant in the longer duration dressing had a slight wound dehiscence at the two-week visit which resolved later with wound care. No complications (including infection and wound status) in the two weeks following surgery were reported in either group in Williams 2008.

5. Return to work or occupation (measured as 'yes' or 'no') at three months

  • Not reported.

6. Change in neurophysiologic parameters (using nerve conduction studies)

  • Not reported.

7. Presence of adverse events as a results of the rehabilitation

  • Not reported in Ritting 2012 or Williams 2008. Complications were reported as iatrogenic symptoms as a result of the surgery rather than the interventions.

 

Subgroup and sensitivity analyses

We could not perform any subgroup analyses in this review. Clinical heterogeneity of interventions and outcomes or paucity of the specified subgroups being distinguished by trialists meant that these analyses were not possible. Furthermore, sensitivity analyses were not performed as there were no meta-analyses.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Summary of main results

The objective of this systematic review was to determine the effectiveness and safety of various rehabilitation treatments to optimise outcomes following CTR, compared with no treatment, a placebo or another nonsurgical intervention. Twenty studies investigating a total of 1445 participants were included. From the included studies, it was determined that there is currently limited and low to very low quality evidence to support the use of a variety of rehabilitation treatments following CTR. The studies were heterogenous in the type of rehabilitation treatments provided, intensity, dosage, duration of the treatment, timing of the treatment, outcome assessments and treatment setting. Therefore, data could not be pooled across studies.

Amongst the quality issues of these studies unit of analysis errors are important. Jeffrey 2002 avoided a unit of analysis error, Finsen 1999 Martins 2006 and Provinciali 2000 committed such errors and this was unclear in Bury 1995, Bhatia 2000 and Li 2008, Therefore, it is important for clinicians and researchers to interpret the results of the studies with caution.

One study compared multiple treatments to a control group (Li 2008); five studies compared one rehabilitation treatment to a no-treatment control group (Fagan 2004; Gordon 2010; Li 2008; Pomerance 2007; Powell 2003); three studies compared one rehabilitation treatment to a placebo (Alves 2011; Jeffrey 2002; Stevinson 2003); 14 studies compared one rehabilitation treatment to other rehabilitation treatments (Bhatia 2000; Bury 1995; Cebesoy 2007; Cook 1995; Finsen 1999; Hochberg 2001; Huemer 2007; Janssen 2009; Li 2008; Martins 2006; Provinciali 2000; Ritting 2012; Stevinson 2003; Williams 2008).

Only four studies reported the primary outcome of interest, that is long-term self reported functional ability at three or more months (Cebesoy 2007; Gordon 2010; Pomerance 2007; Powell 2003). Only three of these trials (Cebesoy 2007; Pomerance 2007; Powell 2003) reported suitable outcome data for inclusion in this review. One high quality trial (Powell 2003) with a small sample size found no statistically significant effect on BCTQ of a desensitisation program over a standard treatment control group. One moderate quality trial (Pomerance 2007) assessed 150 participants at six months post surgery using the DASH questionnaire and found no statistically significant difference in scores in the no therapy group (instructed pre-operatively on tendon gliding exercises, scar massage and return to activity) compared with a two-week course of multimodal therapy commenced at five to seven days post surgery. However, this study only included employed persons and hence this limits the generalisability to non-employed or retired people. One very low quality quasi-randomised trial (Cebesoy 2007) found that participants who received a bulky dressing and commenced early mobilisation reported no statistically significant difference in function on BCTQ at three months post surgery, compared with participants who received a postoperative wrist orthosis at three months post surgery.

Two low quality trials (Bhatia 2000; Bury 1995) compared immobilisation using a wrist orthosis to a bulky dressing and mobilisation. Both reported incomplete data and limited data on measures of variability. Bury 1995 found that the improvement in CTS symptoms in participants who wore a wrist orthosis for two weeks was not statistically significantly different than the improvement in those who wore a bulky dressing. The lack of participant blinding in this study means that the outcomes should be interpreted with caution, as patients' symptom reporting may have been influenced by knowledge of their intervention group.

Four trials (Cebesoy 2007; Cook 1995; Finsen 1999; Martins 2006) compared immobilisation of the wrist using an orthosis with a program of early mobilisation. Studies by Cook 1995 and Finsen 1999 had incomplete data, which limited analysis and reporting of their results. Measures of variability were also missing for a number of outcome measures in each trial, and some outcomes were reported using median values indicating the data may have been skewed (Finsen 1999). Martins 2006 found no significant differences between the two interventions, which suggests that one intervention is not superior over the other in terms of change in CTS symptom severity and sensibility measured using two-point discrimination. No significant differences in iatrogenic symptoms secondary to CTR were found between groups in studies by Cook 1995 and Finsen 1999. Only one study (Cebesoy 2007) reported adverse events related to the intervention. Cebesoy 2007 reported that 80% of participants in the splinted group experienced discomfort compared to none in the mobilisation group, which was a statistically significant difference. However, results from these studies (Cebesoy 2007; Finsen 1999; Martins 2006) should be interpreted with caution as they lacked appropriate randomisation.

Two RCTs (Jeffrey 2002; Stevinson 2003) investigated the use of arnica as an intervention compared with a placebo. The results of Jeffrey 2002 suggested no significant differences in grip strength or swelling after seven days of arnica compared with placebo. Stevinson 2003 found that there was no difference between participants who received either high or low doses of oral arnica when compared with a placebo with respect to bruising of the hand post surgery.

Two trials investigated multimodal hand therapy or physiotherapy compared with either a non-graduated home exercise program (pre-operative education regarding tendon gliding exercises, scar management and advice on return to activity) (Pomerance 2007) or a progressive patient-directed home exercise program (Provinciali 2000). Provinciali 2000 did not report outcome data in a manner that allowed further analysis. Pomerance 2007 found no significant differences between groups in the short-term postoperative period or at three months' follow-up for changes in self reported functional ability and impairment measures using grip or pinch strength.

We identified two trials (Ritting 2012; Williams 2008) that compared short duration postoperative dressing to an extended duration dressing. The study by Williams 2008 found no significant differences between short and longer duration dressings for improved functional status and symptom severity on the BCTQ, whilst the study by Ritting 2012 found that patients who had their dressing removed early had better grip and pinch strength. However, there was no participant blinding in either study. These results should be interpreted with caution as participants' assessments of effectiveness may have been influenced by their awareness of the intervention.

One moderate quality randomised trail by Janssen 2009 found that there was no statistically significant difference in the amount of swelling among participants receiving contrast baths plus exercises compared to those receiving contrast baths alone, though statistically significantly more swelling than those receiving exercise alone. Further, those receiving contrast baths alone had statistically significantly more swelling than those receiving exercises alone.

We identified one randomised trial by Hochberg 2001 which compared the effects of controlled cold therapy to ice therapy commenced immediately post surgery and continued for three days. Results from this trial supported the use of controlled cold therapy over ice therapy for both pain and swelling reduction in the short term. However, participants and outcome assessors in this study were not blinded, which may have influenced their expectations of the effect of the interventions.

We identified one quasi-randomised trial which compared low-level laser therapy to a placebo laser (Alves 2011). Trialists found that there was no statistically significant difference in CTS symptoms with low-level laser therapy compared with a placebo. There were no differences between groups in the return to work outcome at three months post surgery. The results of this trial should be interpreted cautiously as participants were allocated to groups using a quasi-random sequence.

One trial by Fagan 2004 examined elevation using a home elevation device and Bradford sling versus a standard care control group. The trialists found no statistically significant differences between groups in pain or swelling.

Trials conducted by Gordon 2010 (electrical stimulation versus a control group), Huemer 2007 (bulky dressing and splint versus light dressings), Li 2008 (electrical stimulation versus decimeter wave therapy versus a no treatment control) either did not report outcome data in a format that was meaningful, or data were incomplete and could not be analysed.

 

Overall completeness and applicability of evidence

The evidence in this review is limited in its completeness and applicability. There were a number of important details about the conduct of studies and reporting of data that were not provided by the authors of the included studies. A wide variety of rehabilitation treatments are included in this review which makes it difficult to draw conclusions on the overall efficacy of rehabilitation interventions following CTR. In addition, we were unable to include a number of treatments used in rehabilitation (such as ultrasound, scar massage, mobilisation techniques, strengthening, return-to-work interventions and work modification) in this review because there were no RCTs that evaluated their efficacy. Moreover, two studies (Pomerance 2007; Provinciali 2000) investigated the benefit of a program of multimodal hand therapy, making it difficult to isolate the interventions within the multi-component treatment that could be effective. A number of studies did not report demographic data including gender and age distribution, setting, details of the type of CTS, and eligibility criteria, which limits the potential to generalise findings to a certain population or treatment setting. Only three studies (Alves 2011; Gordon 2010; Pomerance 2007) clearly reported results of interventions at three months or more.

 

Quality of the evidence

The methodological quality varied greatly across studies. All the studies were small, ranging from 21 (Gordon 2010) to a maximum of 150 participants (Pomerance 2007). Four of the studies had 100 or more participants who underwent CTR and were randomised (Bhatia 2000; Pomerance 2007; Provinciali 2000; Williams 2008). Overall, the risk of bias was high in most studies. Only 11 trials (Bhatia 2000; Bury 1995; Fagan 2004; Gordon 2010; Hochberg 2001; Janssen 2009; Pomerance 2007; Powell 2003; Ritting 2012; Stevinson 2003; Williams 2008) explicitly reported that the sequence was generated in a randomised fashion. Three trials (Pomerance 2007; Powell 2003; Stevinson 2003) adequately concealed the allocation sequence. This is important as inadequate allocation concealment can lead to distortion of treatment effects (Odgaard-Jensen 2011). Four studies (Janssen 2009; Jeffrey 2002; Powell 2003; Stevinson 2003) achieved blinding of both participants and outcome assessors. Lack of blinding of the participants is often unavoidable in situations where the interventions are obvious (for example, type of dressing or intervention versus lack thereof). However, outcomes in these studies should be interpreted with caution due to empirical evidence that lack of blinding may lead to exaggerated treatment effects (Wood 2008). In comparison, blinding of outcome assessors is nearly always possible but was not clearly reported in 11 out of the 20 studies (Alves 2011; Bhatia 2000; Bury 1995; Cebesoy 2007; Cook 1995; Fagan 2004; Finsen 1999; Gordon 2010; Hochberg 2001; Huemer 2007; Li 2008; ). The risk of bias from incomplete outcome data was unclear or high for both short-term and long-term data in five studies (Bhatia 2000; Bury 1995; Cook 1995; Finsen 1999; Provinciali 2000), whilst eight studies had a high risk of bias from selective reporting (Bury 1995; Cook 1995; Fagan 2004; Finsen 1999; Gordon 2010; Huemer 2007; Pomerance 2007; Provinciali 2000). Studies with high risk of selective reporting bias are problematic as they can bias the results and conclusions of a systematic review (Kirkham 2010).

 

Potential biases in the review process

While our methods attempted to minimise bias in the selection of studies for the review, collection of published data and analysis, our searches were limited to electronic databases and clinical trial registries. Although we have included one unpublished study (Powell 2003) identified through a clinical trials database, results of some unpublished studies may have been missed. Furthermore, it was also difficult to obtain all relevant data required for a systematic review from the authors of the included studies, often due to the length of time since some of the studies were completed. It was also difficult to assess selective outcome reporting for some of the studies where study protocols or trial registry data were not available or accessible and where the study authors did not adequately report the methods used.

 

Agreements and disagreements with other studies or reviews

To our knowledge only three other systematic reviews have been published in this domain (Huisstede 2010; Isaac 2010; Keilani 2002). Keilani 2002 published a review in German which reviewed the effect of mobilisation and splinting interventions on symptoms following CTR by reviewing both randomised and non-randomised studies. This review is awaiting translation. Isaac 2010 reviewed RCTs that compared wrist immobilisation to another intervention or control group in studies that had over 30 participants who had open CTR and were published in English. The Isaac 2010 review identified articles by Bury 1995; Cebesoy 2007; Cook 1995; Finsen 1999; Martins 2006. Huisstede 2010 briefly reviewed rehabilitation interventions following CTR as part of a larger review on the effectiveness of CTR and identified articles by Bury 1995, Cebesoy 2007, Chaise 1994, Cook 1995, Finsen 1999, Hochberg 2001, Huemer 2007, Jeffrey 2002, Martins 2006, Pomerance 2007, Provinciali 2000 and Stevinson 2003. Huisstede 2010 listed the trial by Cook 1995 as a pre-operative intervention rather than a postoperative intervention and it is not clear why it was classified this way.

The findings of our review are generally consistent with the findings of Isaac 2010 and Huisstede 2010 in concluding that there is limited and insufficient evidence to determine a beneficial effect from immobilisation post CTS surgery. However, we believe this review is the most comprehensive yet, as the review by Isaac 2010 did not include the study by Bhatia 2000 and Huisstede 2010 did not include Fagan 2004, Li 2008 or Williams 2008. It is unclear why the search strategies did not identify these trials.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

 

Implications for practice

There is limited and very low quality evidence for rehabilitation treatments following CTR. People who have undergone CTR should be provided with sufficient information to make an informed decision about any recommended treatments. They should be informed of the limited evidence of effectiveness and safety of any interventions recommended by the treatment provider. Treatment providers and referrers for treatment should consider the environmental context, nature of the intervention and the patient's preference before recommending a rehabilitation treatment following surgery for CTS. The benefit of rehabilitation treatments in the short term compared to the long term have not been adequately evaluated.

 
Implications for research

Carpal tunnel release surgery is generally successful in reducing the symptoms of CTS and has few reported adverse events (Verdugo 2008). Therefore, the effects of interventions in improving postoperative outcomes, including function and return to work, need large samples to have the power to detect statistically significant differences between groups. The high success rate of surgery may also contribute to the lack of high quality studies. Secondly, a wide variety of poor outcomes are possible after surgery and it can be difficult to design a study examining multiple outcomes and also control the various confounding variables. This is because poor outcomes can result from either: a failure to relieve the pre-existing symptoms or iatrogenic complications from the surgery itself (for example, scar pain, hypersensitivity or reduced grip strength). However, for those patients who do have persistent symptoms or iatrogenic effects as a result of CTR, research into the effects of various rehabilitation modalities is still relevant and necessary.

Therefore, there is a need for more high quality RCTs to assess the effectiveness and safety of rehabilitation treatments delivered following CTR. There are a number of issues that researchers need to consider when designing a study. These trials should attempt to blind participants and outcome assessors where possible. Trial authors should clearly report demographic details and rehabilitation setting information so that results can be interpreted and applied to similar populations and settings. In addition, data on adverse effects of the rehabilitation intervention rather than the iatrogenic effects of the surgery should be recorded. If participants with bilateral CTS are included in the study, trialists should use appropriate methods and clearly report how bilateral cases were handled in their statistical analysis to prevent a unit of analysis error. Authors should also place trial information on the appropriate clinical trials registers to provide transparent reporting of the methods planned for their study. Moreover, trialists should be careful to include in the study report means and appropriate measures of variability for all outcomes prespecified in their methods, thereby avoiding selective reporting bias. The nature of these interventions and the results reported by trials included in this review, mean that benefit may be observed for early return to function and return-to-work that is not observed at three months or more. However, longer-term effectiveness should not be ignored. Assessment of longer-term benefit following cessation of the intervention should be incorporated in future research. Researchers should focus on postoperative care regimes that have been designed to reduce the symptoms of CTS. They need to measure the severity and type of CTS symptoms pre-operatively and should stratify the patient population accordingly. Additionally, consistent reporting of outcomes (common instruments and timing of outcome assessments) will allow for meta-analysis of similar outcomes in future reviews. The only consistent effects of treatment were in CTS symptom scores and these outcomes therefore might be useful in future studies. Finally, many commonly used rehabilitation treatments have not yet been evaluated for their effectiveness or safety, and these should be included future trials.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

We would like to acknowledge Denise O'Connor and Cathy Dabourn who produced the initial protocol for this review in 2003. We would like to thank Angela Gunn and Ruth Brassington from the Cochrane Neuromuscular Group for their assistance in devising the search strategy, and editorial support. We would also like to thank the trialists that provided additional information on the included studies.

We would also like to thank the following institutions for their support during the review:

  • Brisbane Hand and Upper Limb Research Institute, Brisbane, AUSTRALIA
  • School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, AUSTRALIA

Editorial support from the Cochrane Neuromuscular Disease Group is funded by the MRC Centre for Neuromuscular Diseases.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
Download statistical data

 
Comparison 1. Low-level laser versus placebo

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Change in CTS symptoms (night time pain)1Risk Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 At 1 month post surgery
158Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    1.2 At 2 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    1.3 At 3 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    1.4 At 6 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 2 Change in CTS symptoms (palmar pain)1Risk Ratio (M-H, Random, 95% CI)Subtotals only

    2.1 At 1 month post surgery
158Risk Ratio (M-H, Random, 95% CI)0.73 [0.34, 1.54]

    2.2 At 2 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.17 [0.02, 1.30]

    2.3 At 3 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.33 [0.01, 7.86]

    2.4 At 6 months post surgery
158Risk Ratio (M-H, Random, 95% CI)1.0 [0.07, 15.24]

 3 Change in CTS symptoms (numbness)1Risk Ratio (M-H, Random, 95% CI)Subtotals only

    3.1 At 1 month post surgery
158Risk Ratio (M-H, Random, 95% CI)0.38 [0.11, 1.27]

    3.2 At 2 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.08 [0.00, 1.31]

    3.3 At 3 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.14 [0.01, 2.65]

    3.4 At 6 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.2 [0.01, 3.99]

 4 Change in CTS symptoms (paraesthesia)1Risk Ratio (M-H, Random, 95% CI)Subtotals only

    4.1 At 1 month post surgery
158Risk Ratio (M-H, Random, 95% CI)0.38 [0.11, 1.27]

    4.2 At 2 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.08 [0.00, 1.31]

    4.3 At 3 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.14 [0.01, 2.65]

    4.4 At 6 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.2 [0.01, 3.99]

 5 Number with CTS clinical signs (Durkan's, Tinel's, Phalen's tests, numbness, paraesthesia, nighttime pain)1Risk Ratio (M-H, Random, 95% CI)Subtotals only

    5.1 At 1 month post surgery
158Risk Ratio (M-H, Random, 95% CI)3.00 [0.33, 27.18]

    5.2 At 2 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.14 [0.01, 2.65]

    5.3 At 3 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    5.4 At 6 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 6 Iatrogenic symptoms (scar pain)1Risk Ratio (M-H, Random, 95% CI)Subtotals only

    6.1 At 1 month post surgery
158Risk Ratio (M-H, Random, 95% CI)0.56 [0.30, 1.06]

    6.2 At 2 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.5 [0.14, 1.81]

    6.3 At 3 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.33 [0.04, 3.02]

    6.4 At 6 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.33 [0.01, 7.86]

 7 Iatrogenic symptoms (pillar pain)1Risk Ratio (M-H, Random, 95% CI)Subtotals only

    7.1 At 1 month post surgery
158Risk Ratio (M-H, Random, 95% CI)1.33 [0.53, 3.36]

    7.2 At 2 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.57 [0.19, 1.74]

    7.3 At 3 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.67 [0.21, 2.12]

    7.4 At 6 months post surgery
158Risk Ratio (M-H, Random, 95% CI)0.33 [0.01, 7.86]

 8 Return to ADL or work (6 months)158Risk Ratio (M-H, Random, 95% CI)1.0 [0.94, 1.07]

 9 Adverse events (surgery)158Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 
Comparison 2. Immobilisation (wrist splint) versus mobilisation (bulky dressing)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Change in CTS symptoms (patient report of being symptom free)1Risk Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 At a mean of 6 months follow-up
143Risk Ratio (M-H, Random, 95% CI)0.94 [0.52, 1.70]

 2 Long-term change in CTS symptoms (number of patients who reported being 'improved' or 'cured')1Risk Ratio (M-H, Random, 95% CI)Subtotals only

    2.1 At a mean of 6 months follow-up
143Risk Ratio (M-H, Random, 95% CI)0.90 [0.76, 1.06]

 3 Return to normal occupations143Risk Ratio (M-H, Fixed, 95% CI)0.83 [0.62, 1.11]

    3.1 At a mean of 5.7 months follow-up
143Risk Ratio (M-H, Fixed, 95% CI)0.83 [0.62, 1.11]

 4 Adverse effects143Risk Ratio (M-H, Fixed, 95% CI)0.22 [0.01, 5.16]

 
Comparison 3. Immobilisation (plaster of Paris splint) versus bulky dressing and mobilisation

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Long-term improvement in functional ability (BCTQ Functional Status Score)1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    1.1 At 3 months
140Mean Difference (IV, Fixed, 95% CI)0.39 [-0.45, 1.23]

 2 Short-term improvement in functional ability (BCTQ Functional Status Score)1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    2.1 At 1 month
140Mean Difference (IV, Fixed, 95% CI)0.60 [-0.95, 2.15]

 3 Change in CTS symptoms (BCTQ Symptom Severity Score)2Mean Difference (IV, Random, 95% CI)Subtotals only

    3.1 At 2 weeks post surgery
152Mean Difference (IV, Random, 95% CI)-0.95 [-3.49, 1.59]

    3.2 Change score between baseline and at 2 weeks
152Mean Difference (IV, Random, 95% CI)0.03 [-0.04, 0.10]

    3.3 At 1 month post surgery
140Mean Difference (IV, Random, 95% CI)-0.34 [-1.53, 0.85]

    3.4 At 3 months post surgery
140Mean Difference (IV, Random, 95% CI)1.60 [-0.12, 3.32]

 4 Change in CTS symptoms (Symptom Intensity Score)1Mean Difference (IV, Random, 95% CI)Subtotals only

    4.1 At 2 weeks post surgery
152Mean Difference (IV, Random, 95% CI)-0.77 [-1.68, 0.14]

 5 Change score between baseline and 2 weeks (Symptom Intensity Score)152Mean Difference (IV, Random, 95% CI)0.11 [-0.01, 0.23]

 6 Change in impairment (sensibility measured using static two-point discrimination)1Mean Difference (IV, Random, 95% CI)Subtotals only

    6.1 At 2 weeks post surgery
152Mean Difference (IV, Random, 95% CI)-1.43 [-2.50, -0.36]

 7 Change score between baseline and 2 weeks (Discrimination Index)152Mean Difference (IV, Random, 95% CI)-0.02 [-0.17, 0.13]

 8 Iatrogenic Symptoms2Risk Ratio (M-H, Random, 95% CI)Subtotals only

    8.1 Scar tenderness at 1 month post surgery
150Risk Ratio (M-H, Random, 95% CI)1.75 [0.90, 3.42]

    8.2 Pillar pain at 1 month post surgery
150Risk Ratio (M-H, Random, 95% CI)2.4 [0.99, 5.81]

    8.3 Scar discomfort/pain at 6 weeks
181Risk Ratio (M-H, Random, 95% CI)0.95 [0.59, 1.54]

    8.4 Hypothenar pain at 6 weeks
181Risk Ratio (M-H, Random, 95% CI)1.25 [0.39, 3.99]

    8.5 Thenar pain at 6 weeks
181Risk Ratio (M-H, Random, 95% CI)2.5 [0.24, 26.48]

    8.6 Scar discomfort/pain at 6 months
181Risk Ratio (M-H, Random, 95% CI)1.19 [0.42, 3.38]

    8.7 Hypothenar pain at 6 months
181Risk Ratio (M-H, Random, 95% CI)3.57 [0.39, 32.87]

    8.8 Thenar pain at 6 months
181Risk Ratio (M-H, Random, 95% CI)1.19 [0.08, 18.36]

 9 Adverse event2Risk Ratio (M-H, Random, 95% CI)Subtotals only

    9.1 Discomfort or heavy feeling caused by intervention
140Risk Ratio (M-H, Random, 95% CI)33.0 [2.11, 515.02]

    9.2 Bowstringing of flexor tendons
290Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    9.3 Wound dehiscence
150Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 
Comparison 4. Specialised home elevation device versus standard sling

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Short-term improvement in CTS symptoms (VAS pain 0-10) (3 months or less)1Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 At the end of 5 days treatment
141Mean Difference (IV, Random, 95% CI)-0.5 [-1.36, 0.36]

 2 Iatrogenic symptoms (swelling)1Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 At the end of 5 days treatment
141Mean Difference (IV, Random, 95% CI)4.0 [-40.27, 48.27]

 
Comparison 5. Controlled cold therapy versus ice therapy

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Short-term improvement in CTS symptoms (VAS pain 0-10) (3 months or less)1Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 At the end of 3 days treatment (per protocol analysis)
144Mean Difference (IV, Random, 95% CI)-2.8 [-4.50, -1.10]

    1.2 At the end of 3 days treatment (intention-to-treat analysis)
165Mean Difference (IV, Random, 95% CI)-1.90 [-3.51, -0.29]

    1.3 Change from baseline to day 3 (per protocol analysis)
142Mean Difference (IV, Random, 95% CI)-2.8 [-4.88, -0.72]

    1.4 Change from baseline to day 3 (intention-to-treat analysis)
163Mean Difference (IV, Random, 95% CI)-1.40 [-3.24, 0.44]

 2 Iatrogenic symptoms (swelling)1Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 At the end of 3 days treatment (per protocol analysis)
148Mean Difference (IV, Random, 95% CI)0.0 [-1.02, 1.02]

    2.2 At the end of 3 days treatment (intention-to-treat analysis)
172Mean Difference (IV, Random, 95% CI)-0.40 [-1.21, 0.41]

    2.3 Change from baseline to day 3 (per protocol analysis)
147Mean Difference (IV, Random, 95% CI)-1.0 [-1.26, -0.74]

    2.4 Change from baseline to day 3 (intention-to-treat analysis)
171Mean Difference (IV, Random, 95% CI)-1.1 [-1.33, -0.87]

 
Comparison 6. Bulky dressing plus splint versus light dressing

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Iatrogenic symptom (scar pain)150Risk Ratio (M-H, Random, 95% CI)5.0 [0.25, 99.16]

 2 Adverse event (median nerve, digital nerve, vascular, tendon complications, delayed wound healing)150Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 
Comparison 7. Contrast bath plus exercise versus contrast bath

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Iatrogenic symptom (swelling)1Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 Post treatment
142Mean Difference (IV, Random, 95% CI)-8.80 [-22.23, 4.63]

 
Comparison 8. Contrast bath plus exercises versus exercise

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Iatrogenic symptom (swelling)1Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 Post treatment
133Mean Difference (IV, Random, 95% CI)23.20 [3.60, 42.80]

 
Comparison 9. Contrast bath versus exercise

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Iatrogenic symptom (swelling)1Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 Post treatment
137Mean Difference (IV, Random, 95% CI)32.0 [12.61, 51.39]

 
Comparison 10. Arnica versus placebo

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Change in impairment measure (grip strength)1Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 At 1 week post surgery
174Mean Difference (IV, Random, 95% CI)11.40 [-3.78, 26.58]

    1.2 At 2 weeks post surgery
174Mean Difference (IV, Random, 95% CI)5.40 [-18.63, 29.43]

 2 Iatrogenic symptom (swelling; % wrist circumference change difference)1Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 At 1 week post surgery
174Mean Difference (IV, Random, 95% CI)0.20 [-0.53, 0.93]

    2.2 At 2 weeks post surgery
174Mean Difference (IV, Random, 95% CI)-0.30 [-1.34, 0.74]

 
Comparison 11. High dose arnica oral tablets versus placebo

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Iatrogenic symptoms (number of patients with no clinician-rated bruising)1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    1.1 At 4 days
142Risk Ratio (M-H, Fixed, 95% CI)1.83 [0.50, 6.71]

    1.2 At 9 days
142Risk Ratio (M-H, Fixed, 95% CI)1.38 [0.43, 4.42]

    1.3 At 14 days
142Risk Ratio (M-H, Fixed, 95% CI)1.1 [0.42, 2.86]

 2 Adverse effects1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    2.1 Arnica 30C vs placebo
140Risk Ratio (M-H, Fixed, 95% CI)1.0 [0.23, 4.37]

 
Comparison 12. Low dose arnica tablets versus placebo

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Iatrogenic symptoms (number of patients with no clinician-rated bruising)1Risk Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 At 4 days
142Risk Ratio (M-H, Random, 95% CI)1.83 [0.50, 6.71]

    1.2 At 9 days
142Risk Ratio (M-H, Random, 95% CI)0.83 [0.21, 3.24]

    1.3 At 14 days
140Risk Ratio (M-H, Random, 95% CI)0.67 [0.22, 2.01]

 2 Adverse events140Risk Ratio (M-H, Random, 95% CI)0.67 [0.12, 3.57]

 
Comparison 13. High dose versus low dose oral arnica tablets

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Iatrogenic symptoms (number of patients with no clinician-rated bruising)1Risk Ratio (M-H, Random, 95% CI)Subtotals only

    1.1 At 4 days
140Risk Ratio (M-H, Random, 95% CI)1.0 [0.34, 2.93]

    1.2 At 9 days
140Risk Ratio (M-H, Random, 95% CI)1.67 [0.46, 6.06]

    1.3 At 14 days
140Risk Ratio (M-H, Random, 95% CI)1.5 [0.50, 4.52]

 2 Adverse events140Risk Ratio (M-H, Fixed, 95% CI)1.5 [0.28, 8.04]

 
Comparison 14. Multimodal hand therapy versus normal activities/exercise

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Long-term improvement in functional ability (BCTQ Functional Status Score)1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    1.1 DASH at 6 months post surgery
1150Mean Difference (IV, Fixed, 95% CI)1.0 [-4.44, 6.44]

 2 Change in impairment measure (grip strength)1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    2.1 At the end of 2 weeks' treatment (2 weeks post surgery)
1150Mean Difference (IV, Fixed, 95% CI)-0.70 [-4.00, 2.60]

    2.2 2 weeks after treatment ended (4 weeks post surgery)
1150Mean Difference (IV, Fixed, 95% CI)0.20 [-2.83, 3.23]

    2.3 4 weeks after treatment ended (6 weeks post surgery)
1150Mean Difference (IV, Fixed, 95% CI)0.10 [-2.81, 3.01]

    2.4 10 weeks after treatment ended (12 weeks post surgery)
1150Mean Difference (IV, Fixed, 95% CI)-0.60 [-3.43, 2.23]

    2.5 6 months post-surgery
1150Mean Difference (IV, Fixed, 95% CI)-0.40 [-3.59, 2.79]

 3 Change in impairment measure (lateral pinch strength)1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    3.1 At the end of 2 weeks' treatment (2 weeks post surgery)
1150Mean Difference (IV, Fixed, 95% CI)-0.70 [-1.42, 0.02]

    3.2 2 weeks after treatment ended (4 weeks post surgery)
1150Mean Difference (IV, Fixed, 95% CI)0.0 [-0.67, 0.67]

    3.3 4 weeks after treatment ended (6 weeks post surgery)
1150Mean Difference (IV, Fixed, 95% CI)-0.10 [-0.89, 0.69]

    3.4 10 weeks after treatment ended (12 weeks post surgery)
1150Mean Difference (IV, Fixed, 95% CI)-0.20 [-0.97, 0.57]

    3.5 6 months post surgery
1150Mean Difference (IV, Fixed, 95% CI)-0.20 [-0.94, 0.54]

 4 Return to normal occupations1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    4.1 At the end of treatment (2 weeks post surgery)
1150Risk Ratio (M-H, Fixed, 95% CI)0.96 [0.78, 1.18]

    4.2 4 weeks after treatment ended (6 weeks post surgery)
1150Risk Ratio (M-H, Fixed, 95% CI)1.02 [0.89, 1.17]

    4.3 6 weeks after treatment ended (8 weeks post surgery)
1150Risk Ratio (M-H, Fixed, 95% CI)1.04 [0.97, 1.12]

 5 Adverse effects1150Risk Ratio (M-H, Fixed, 95% CI)0.53 [0.05, 5.69]

 
Comparison 15. Desensitisation therapy (as part of multiple interventions) versus no treatment

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Long-term improvement in functional ability (BCTQ Functional Status Score)127Mean Difference (IV, Random, 95% CI)-0.03 [-0.39, 0.33]

    1.1 At 12 weeks post surgery
127Mean Difference (IV, Random, 95% CI)-0.03 [-0.39, 0.33]

 2 Short-term improvement in functional ability (BCTQ Functional Status Score)1Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 At 3 weeks post surgery
127Mean Difference (IV, Random, 95% CI)-0.30 [-0.76, 0.16]

    2.2 At 6 weeks post surgery
127Mean Difference (IV, Random, 95% CI)0.02 [-0.35, 0.39]

 3 Change in CTS symptoms (pain or discomfort)1Mean Difference (IV, Random, 95% CI)Subtotals only

    3.1 At 3 weeks post surgery
127Mean Difference (IV, Random, 95% CI)-13.30 [-27.29, 0.69]

    3.2 At 6 weeks post surgery
127Mean Difference (IV, Random, 95% CI)-9.40 [-23.87, 5.07]

    3.3 At 12 weeks post surgery
127Mean Difference (IV, Random, 95% CI)4.9 [-14.69, 24.49]

 4 Change in impairment measure (grip strength)1Mean Difference (IV, Random, 95% CI)Subtotals only

    4.1 At 3 weeks post surgery
127Mean Difference (IV, Random, 95% CI)0.41 [-3.95, 4.77]

    4.2 At 6 weeks post surgery
127Mean Difference (IV, Random, 95% CI)1.80 [-4.01, 7.61]

    4.3 At 12 weeks post surgery
127Mean Difference (IV, Random, 95% CI)-0.80 [-7.38, 5.78]

 5 Iatrogenic symptoms (scar sensitivity using dolorimetry)1Mean Difference (IV, Random, 95% CI)Subtotals only

    5.1 At 3 weeks post surgery
127Mean Difference (IV, Random, 95% CI)0.26 [-0.30, 0.82]

    5.2 At 6 weeks post surgery
127Mean Difference (IV, Random, 95% CI)0.16 [-0.49, 0.81]

    5.3 At 12 weeks post surgery
127Mean Difference (IV, Random, 95% CI)-0.67 [-1.46, 0.12]

 6 Adverse events (wound dehiscence)127Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 
Comparison 16. Short duration dressing versus extended duration dressing

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Short-term improvement in functional ability (BCTQ Functional Status Score)1Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 At 2 weeks post surgery
1100Mean Difference (IV, Random, 95% CI)0.10 [-0.25, 0.45]

    1.2 Change in Functional Status Score baseline to 2 weeks
1100Mean Difference (IV, Random, 95% CI)0.40 [0.05, 0.75]

 2 Change in CTS symptoms (BCTQ Symptom Severity Score)1Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 At 2 weeks
1100Mean Difference (IV, Random, 95% CI)0.0 [-0.26, 0.26]

    2.2 Change in Symptom Severity Score baseline to 2 weeks
1100Mean Difference (IV, Random, 95% CI)0.30 [0.01, 0.59]

 3 Change in impairment measure (grip strength)166Mean Difference (IV, Random, 95% CI)-16.0 [-21.57, -10.43]

    3.1 At 6-12 weeks
166Mean Difference (IV, Random, 95% CI)-16.0 [-21.57, -10.43]

 4 Change in impairment measure (pinch strength)1Mean Difference (IV, Random, 95% CI)Subtotals only

    4.1 Tip pinch 6-12 weeks
166Mean Difference (IV, Random, 95% CI)-1.20 [-2.35, -0.05]

    4.2 Three point pinch at 6-12 weeks
166Mean Difference (IV, Random, 95% CI)-1.10 [-2.28, 0.08]

    4.3 Lateral pinch at 6-12 weeks
166Mean Difference (IV, Random, 95% CI)-0.70 [-1.88, 0.48]

 5 Adverse event2166Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Appendix 1. MEDLINE (OvidSP) search strategy

Database: Ovid MEDLINE(R) <1946 to March Week 3 2012>
Search Strategy:
--------------------------------------------------------------------------------
1 randomised controlled trial.pt. (322018)
2 controlled clinical trial.pt. (83725)
3 randomized.ab. (227059)
4 placebo.ab. (129364)
5 drug therapy.fs. (1512981)
6 randomly.ab. (164073)
7 trial.ab. (234125)
8 groups.ab. (1081731)
9 or/1-8 (2806662)
10 exp animals/ not humans.sh. (3686007)
11 9 not 10 (2382300)
12 Carpal Tunnel Syndrome/ (6379)
13 carpal tunnel.mp. (7651)
14 or/12-13 (7651)
15 exp REHABILITATION/ (131274)
16 Postoperative Care/ (48938)
17 exp Musculoskeletal Manipulations/ (10919)
18 exp Exercise Movement Techniques/ (4365)
19 exp Physical Therapy Techniques/ (109381)
20 SPLINTS/ (7104)
21 Casts, Surgical/ (7530)
22 (ultrasound or scar$ or desenti$ or rehabilit$ or work or cold therap$ or ice therapy or splint$ or exercis$ or mobili$ or educat$ or activity modification or ergonomic$).mp. (1573897)
23 (immobili$ or hand elevation or sling or strength$ or oedema$ or edema$ or compress$ or massag$ or gliding or thermotherapy or physical therap$ or physiotherap$ or manual therap$ or occupational therap$ or osteopath$ or chiropract$).mp. (532328)
24 pain, postoperative/ (23627)
25 postoperative.tw. (255189)
26 or/15-25 (2359672)
27 11 and 14 and 26 (550)
28 Decompression, Surgical/ (8308)
29 microvascular decompression surgery/ (11)
30 (surgical or epineurotomy or reconstruct$ or release or decompress$ or endoscop$).tw. (1138166)
31 hand surgery.mp. (1544)
32 or/28-31 (1140886)
33 11 and 14 and 26 and 32 (260)

 

Appendix 2. EMBASE (OvidSP) search strategy

Database: Embase <1980 to 2012 Week 13>
Search Strategy:
--------------------------------------------------------------------------------
1 crossover-procedure.sh. (33411)
2 double-blind procedure.sh. (107964)
3 single-blind procedure.sh. (15640)
4 randomised controlled trial.sh. (318960)
5 (random$ or crossover$ or cross over$ or placebo$ or (doubl$ adj blind$) or allocat$).tw,ot. (853185)
6 trial.ti. (127489)
7 or/1-6 (977857)
8 (animal/ or nonhuman/ or animal experiment/) and human/ (1166426)
9 animal/ or nonanimal/ or animal experiment/ (3250362)
10 9 not 8 (2695118)
11 7 not 10 (895859)
12 limit 11 to embase (692354)
13 carpal tunnel syndrome/ (9658)
14 carpal tunnel syndrome.mp. (10407)
15 ((nerve entrapment or nerve compression or entrapment neuropath$) and carpal).mp. (1653)
16 or/13-15 (10511)
17 rehabilitation/ (33215)
18 postoperative care/ (59518)
19 manipulative medicine/ (7541)
20 physiotherapy/ (43845)
21 splint/ (6575)
22 plaster cast/ (7425)
23 postoperative pain/ (35153)
24 (ultrasound or scar$ or desenti$ or rehabilit$ or work or cold therap$ or ice therapy or splint$ or exercis$ or mobili$ or educat$ or activity modification or ergonomic$).mp. (2226089)
25 (immobili$ or hand elevation or sling or strength$ or oedema$ or edema$ or compress$ or massag$ or gliding or thermotherapy or physical therap$ or physiotherap$ or manual therap$ or occupational therap$ or osteopath$ or chiropract$).mp. (749477)
26 postoperative.tw. (317872)
27 exp "bandages and dressings"/ (29066)
28 or/17-27 (3155412)
29 12 and 16 and 28 (379)
30 (hand surgery or surgical or epineurotomy or reconstruct$ or release or endoscop$ or octr or ectr).mp. (1807281)
31 exp decompression surgery/ (27960)
32 30 or 31 (1822354)
33 12 and 16 and 28 and 32 (166)
34 remove duplicates from 33 (166)

 

Appendix 3. AMED (OvidSP) search strategy

Database: AMED (Allied and Complementary Medicine) <1985 to March 2012>
Search Strategy:
--------------------------------------------------------------------------------
1 Randomized controlled trials/ (1510)
2 Random allocation/ (302)
3 Double blind method/ (428)
4 Single-Blind Method/ (25)
5 exp Clinical Trials/ (3163)
6 (clin$ adj25 trial$).tw. (5381)
7 ((singl$ or doubl$ or treb$ or trip$) adj25 (blind$ or mask$ or dummy)).tw. (2204)
8 placebos/ (517)
9 placebo$.tw. (2484)
10 random$.tw. (12562)
11 research design/ (1668)
12 Prospective Studies/ (439)
13 meta analysis/ (106)
14 (meta?analys$ or systematic review$).tw. (1785)
15 control$.tw. (27180)
16 (multicenter or multicentre).tw. (716)
17 ((study or studies or design$) adj25 (factorial or prospective or intervention or crossover or cross-over or quasi-experiment$)).tw. (9588)
18 or/1-17 (41894)
19 carpal tunnel syndrome/ or carpal tunnel syndrome.tw. (444)
20 ((nerve entrapment or nerve compression or entrapment neuropath$) and carpal).mp. (53)
21 or/19-20 (445)
22 rehabilitation/ (36521)
23 postoperative care/ (1092)
24 exp musculoskeletal manipulations/ (4239)
25 physical therapy modalities/ or exp exercise movement techniques/ (2751)
26 exp physical therapy modalities/ (17399)
27 splints/ (99)
28 (ultrasound or scar$ or rehabilit$ or work or cold therap$ or ice therapy or splint$ or exercis$ or mobili$ or educat$ or activity modification or ergonomic$).mp. (80839)
29 (immobili$ or hand elevation or sling or strength$ or oedema$ or edema$ or compress$ or massag$ or gliding or thermotherapy or physical therap$ or physiotherap$ or manual therap$ or occupational therap$ or osteopath$ or chiropract$).mp. (48973)
30 pain postoperative/ (150)
31 postoperative.tw. (3579)
32 or/22-31 (114068)
33 (hand surgery or surgical or epineurotomy or reconstruct$ or release or decompress$ or endoscop$ or octr or ectr).mp. (7555)
34 18 and 21 and 32 and 33 (20)
35 remove duplicates from 34 (20)

 

Appendix 4. PsycINFO (OvidSP) search strategy

Database: PsycINFO <1806 to March Week 4 2012>
Search Strategy:
--------------------------------------------------------------------------------
1 (random$ or rct or cct or factorial$ or crossover$ or cross over$ or cross-over$ or placebo$ or (doubl$ adj blind$) or (singl$ adj blind$) or assign$ or allocat$ or volunteer$).tw. (209229)
2 carpal tunnel syndrome.mp. (215)
3 (ultrasound or scar$ or desenti$ or rehabilit$ or work or cold therap$ or ice therapy or splint$ or exercis$ or mobili$ or educat$ or activity modification or ergonomic$).mp. (740252)
4 (immobili$ or hand elevation or sling or strength$ or oedema$ or edema$ or compress$ or massag$ or gliding or thermotherapy or physical therap$ or physiotherap$ or manual therap$ or occupational therap$ or osteopath$ or chiropract$).mp. (90953)
5 (postoperative care or manipulation or splint$1).mp. (17139)
6 or/3-5 (817231)
7 (decompression or surgical or epineurotomy or reconstruct$ or release or decompress$ or endoscop$ or octr or ectr).mp. (48446)
8 1 and 2 and 6 and 7 (2)

 

Appendix 5. CINAHL Plus (EBSCOhost) search strategy

Print Search History
Tuesday, April 03, 2012 10:32:07 AM

S30 S18 and S24 and S28 and S29 81
S29 hand surgery or surgical or epineurotomy or reconstruct* or release or endoscop* or octr or ectr 116724
S28 S25 or S26 or S27 819565
S27 bandage* or dressing* or immobili or hand elevation or sling or strength* or oedema* or edema* or compress* or massag* or gliding or thermotherapy or physical therap* or physiotherap* or manual therap* or occupational therap* or osteopath* or chiropract* or postoperative 215056
S26 ultrasound or scar* or desenti* or rehabilit* or work or cold therap or ice therapy or splint* or exercis* or mobili* or educat* or activity modification or ergonomic* 672569
S25 (MH "Manual Therapy+") OR (MH "Massage") OR (MH "Manipulation, Osteopathic") OR (MH "Rehabilitation") OR (MH "Hand Therapy") OR (MH "Physical Therapy") OR (MH "Cryotherapy") 56183
S24 s19 or s20 or s21 or s22 or s23 1866
S23 entrapment neuropath* and carpal 43
S22 nerve compression and carpal 145
S21 nerve entrapment and carpal 53
S20 carpal tunnel syndrome 1859
S19 (MH "Carpal Tunnel Syndrome") 1637
S18 S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11 or S12 or S13 or S14 or S15 or S16 or S17 529231
S17 ABAB design* 73
S16 TI random* or AB random* 108199
S15 ( TI (cross?over or placebo* or control* or factorial or sham? or dummy) ) or ( AB (cross?over or placebo* or control* or factorial or sham? or dummy) ) 223769
S14 ( TI (clin* or intervention* or compar* or experiment* or preventive or therapeutic) or AB (clin* or intervention* or compar* or experiment* or preventive or therapeutic) ) and ( TI (trial*) or AB (trial*) ) 75278
S13 ( TI (meta?analys* or systematic review*) ) or ( AB (meta?analys* or systematic review*) ) 21661
S12 ( TI (single* or doubl* or tripl* or trebl*) or AB (single* or doubl* or tripl* or trebl*) ) and ( TI (blind* or mask*) or AB (blind* or mask*) ) 17681
S11 PT ("clinical trial" or "systematic review") 100340
S10 (MH "Factorial Design") 807
S9 (MH "Concurrent Prospective Studies") or (MH "Prospective Studies") 174179
S8 (MH "Meta Analysis") 13791
S7 (MH "Solomon Four-Group Design") or (MH "Static Group Comparison") 30
S6 (MH "Quasi-Experimental Studies") 5297
S5 (MH "Placebos") 7438
S4 (MH "Double-Blind Studies") or (MH "Triple-Blind Studies") 23817
S3 (MH "Clinical Trials+") 139220
S2 (MH "Crossover Design") 9059
S1 (MH "Random Assignment") or (MH "Random Sample") or (MH "Simple Random Sample") or (MH "Stratified Random Sample") or (MH "Systematic Random Sample") 55783

 

Appendix 6. LILACS search strategy

carpal tunnel syndrome [Words] and (Rehabilitation or postoperative care or musculoskeletal manipulation$ or movement technique$ or physical therapy or splint$ or cast or casts or ultrasound or scar or desenti$ or rehabilit$ or work or cold therap$ or ice therapy or splint$ or exercis$ or mobili$ or educat$ or activity modification or ergonomic$ or immobili$ or hand elevation or sling or strength$ or oedema$ or edema$ or compress$ or massag$ or gliding or thermotherapy or physical therap$ or physiotherap$ or manual therap$ or occupational therap$ or osteopath$ or chiropract$) and (decompression surgicalor surgical decompression or decompression surgery or surgical or epineurotomy or reconstruct$ or release or decompress$ or endoscop$ or hand surgery) [Words] and ((Pt randomised controlled trial OR Pt controlled clinical trial OR Mh randomised controlled trials OR Mh random allocation OR Mh double-blind method OR Mh single-blind method) AND NOT (Ct animal AND NOT (Ct human and Ct animal)) OR (Pt clinical trial OR Ex E05.318.760.535$ OR (Tw clin$ AND (Tw trial$ OR Tw ensa$ OR Tw estud$ OR Tw experim$ OR Tw investiga$)) OR ((Tw singl$ OR Tw simple$ OR Tw doubl$ OR Tw doble$ OR Tw duplo$ OR Tw trebl$ OR Tw trip$) AND (Tw blind$ OR Tw cego$ OR Tw ciego$ OR Tw mask$ OR Tw mascar$)) OR Mh placebos OR Tw placebo$ OR (Tw random$ OR Tw randon$ OR Tw casual$ OR Tw acaso$ OR Tw azar OR Tw aleator$) OR Mh research design) AND NOT (Ct animal AND NOT (Ct human and Ct animal)) OR (Ct comparative study OR Ex E05.337$ OR Mh follow-up studies OR Mh prospective studies OR Tw control$ OR Tw prospectiv$ OR Tw volunt$ OR Tw volunteer$) AND NOT (Ct animal AND NOT (Ct human and Ct animal))) [Words]

 

Appendix 7. CENTRAL search strategy

#1 "Carpal Tunnel Syndrome"
#2 ("nerve entrapment" OR "nerve compression" OR "entrapment neuropath*")
#3 "median nerve entrapment"
#4 (#1 OR #2 OR #3)
#5 MeSH descriptor Rehabilitation explode all trees
#6 MeSH descriptor Musculoskeletal Manipulations explode all trees
#7 MeSH descriptor Physical Therapy Modalities explode all trees
#8 MeSH descriptor Exercise Movement Techniques explode all trees
#9 "postoperative care" or splint or ultrasound or scar or rehabilit* or "cold therapt" or "ice therapy" or exercise or mobili* educat* or "activity modification" or ergonomic*
#10 immobili* or "hand elevation" or sling or strength* or oedema or edema or compress* or massage or gliding or thermotherapy or "physical theapy" or physiotherapy or "manual therapy" or "occupational therapy" or osteopath* or chiropract* or postoperative
#11 surgical NEAR/2 cast or surgical NEAR/2 casts
#12 (#5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11)
#13 (#4 AND #12)
#14 "hand surgery" or surgical or epineurotomy or decompress* or reconstruct* or release or endoscop* or octr or ectr
#15 (#13 AND #14)

 

Appendix 8. PEDRO search strategy

#1 "Carpal Tunnel"

 

Appendix 9. Glossary

Bowstringing of the tendons - tendon takes the shortest route across the wrist joint

Cryotherapy - therapeutic intervention using ice

Double crush syndrome - compression of a nerve at more than one site (eg. at the neck and the wrist)

Epineurotonomy - division of a thickened nerve sheath or epineurum

Iatrogenic symptoms - inadvertent adverse complication resulting from medical treatment

Internal neurolysis - removal of scar tissue from the nerve

Palmar arch injury - injury to an artery in the hand

Paraesthesia - sensation of tingling or burning

Pillar pain - tenderness on the base of the palm superficial to the carpal tunnel

Synovectomy - surgical removal of a part of the synovial membrane (lining) of a joint

 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

SUSAN PETERS (SP) was involved in the following aspects of the review: design of the review (in collaboration with the previous protocol authors); undertaking the search of studies (in addition to Angela Gunn of the Cochrane Neuromuscular Disease Group); screening the search results (independently of, but in addition to MP); organising retrieval of papers; screening retrieved papers against inclusion/exclusion criteria (independently of, but in addition to MP); appraising the risk of bias of papers (independently of, but in addition to MP); data extraction from included studies (independently of, but in addition to MP); writing to study investigators for additional information; summarising the risk of bias of the studies; compiling the summary of comparisons, table of included, excluded, awaiting and ongoing studies; entering data into RevMan; performing analysis of data; interpreting the findings; writing of the review; final approval of the version to be published.

MATTHEW PAGE (MP) was involved in the following aspects of the review: design of the review (in collaboration with the previous protocol authors); screening the search results (independently of, but in addition to SP); screening retrieved papers against inclusion/exclusion criteria (independently of, but in addition to SP); appraising the risk of bias of papers (independently of, but in addition to SP); data extraction from included studies (independently of, but in addition to SP); entering data into RevMan; performing analysis of data; interpreting the findings; writing of the review; final approval of the version to be published.

VENERINA JOHNSON (VJ) was involving in the following aspects of the review: design of the review (in collaboration with the previous protocol authors); designated third assessor for disputes; interpreting the findings; writing of the review; final approval of the version to be published.

MICHEL COPPIETERS (MC) was involved in the following aspects of the review: design of the review (in collaboration with the previous protocol authors); interpreting the findings; writing of the review; final approval of the version to be published.

MARK ROSS (MR) was involved in the following aspects of the review: interpreting the findings; writing of the review; final approval of the version to be published.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

The authors have no known conflicts of interest.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms
 

Internal sources

  • Brisbane Hand and Upper Limb Rehabilitation Institute, Brisbane, Australia.
  • Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Australia.

 

External sources

  • No external sources of support were provided for this review, Not specified.

 

Differences between protocol and review

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Sources of support
  14. Differences between protocol and review
  15. Index terms

'Risk of bias' methods were updated and outcomes for inclusion in 'Summary of findings' tables added. Background information was updated to reflect changes in the literature since the protocol was published in 2003. We updated references to previous versions of RevMan software. 'Types of interventions' included in this review were clarified to include rehabilitation interventions, and exclude interventions related to postoperative analgesia. Outcomes from the original protocol (O'Connor 2003) were modified for the review to be consistent with other Cochrane reviews on CTS (Marshall 2007; Scholten 2007; Verdugo 2008; Page 2012a; Page 2012b; Page 2012c; O'Connor 2012). In addition, secondary outcomes regarding return to work were included. Subgroup analyses were amended to reflect current surgical interventions. 'Timing of rehabilitation' and 'other concomitant conditions' subgroup analyses were removed from the review. The sections 'assessment of heterogeneity' and 'sensitivity analysis' have been amended since the protocol was formulated. Sections on 'unit of analysis' and 'assessment of reporting biases' were added.

Denise O'Connor and Cathy Dabourn withdrew from authorship following publication of the protocol and a new team of authors amended the existing protocol as indicated in this review following the guidelines in the Cochrane Handbook (Higgins 2011).

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. References to studies awaiting assessment
  20. References to ongoing studies
  21. Additional references
Alves 2011 {published data only}
Bhatia 2000 {published data only}
Bury 1995 {published data only}
Cebesoy 2007 {published data only}
  • Cebesoy O, Kose KC, Kuru I, Altinel L, Gul R, Demirtas M. Use of a splint following open carpal tunnel release: a comparative study. Advances in Therapy 2007;24(3):478-84. [PUBMED: 17660155]
Cook 1995 {published data only}
  • Cook AC, Szabo RM, Birkholz SW, King EF. Early mobilization following carpal tunnel release. A prospective randomised study. Journal of Hand Surgery (British and European Volume) 1995;20(2):228-30. [PUBMED: 7797977]
Fagan 2004 {published data only}
  • Fagan DJ, Evans A, Ghandour A, Prabhkaran P, Clay NRC. A controlled clinical trial of postoperative hand elevation at home following day-case surgery. Journal of Hand Surgery (British and European Volume) 2004;29(5):458-60. [PUBMED: 15336749]
Finsen 1999 {published and unpublished data}
  • Finsen V, Andersen K, Russwurm H. No advantage from splinting the wrist after open carpal tunnel release. Arandomised study of 82 wrists. Acta Orthopaedica Scandinavica 1999;70(3):288-92. [PUBMED: 10429608]
Gordon 2010 {published data only}
  • Gordon T, Amirjani N, Edwards DC, Chan KM. Brief post-surgical electrical stimulation accelerates axon regeneration and muscle reinnervation without affecting the functional measures in carpal tunnel syndrome patients. Experimental Neurology 2010;223(1):192-202. [PUBMED: 19800329]
Hochberg 2001 {published data only}
  • Hochberg J. A randomised prospective study to assess the efficacy of two cold-therapy treatments following carpal tunnel release. Journal of Hand Therapy 2001;14(3):208-15. [PUBMED: 11511016]
Huemer 2007 {published data only (unpublished sought but not used)}
Janssen 2009 {published data only (unpublished sought but not used)}
  • Janssen RG, Schwartz DA, Velleman PF. A randomized controlled study of contrast baths on patients with carpal tunnel syndrome. Journal of Hand Therapy 2009;22(3):200-7. [PUBMED: 19375278]
Jeffrey 2002 {published data only (unpublished sought but not used)}
  • Jeffrey SLA, Belcher HJCR. Use of Arnica to relieve pain after carpal-tunnel release surgery. Alternative Therapies in Health and Medicine 2002;8(2):66-8. [PUBMED: 11892685]
Li 2008 {published data only (unpublished sought but not used)}
  • Li G, Tian D, Yu J, Li W, Meng J. Synergistic effects of compound physical factor treatment on neurological outcome after peripheral nerve entrapment surgery. Neural Regeneration Research 2008;3(1):97-100. [EMBASE: 2008144777]
Martins 2006 {published and unpublished data}
  • Martins RS, Siqueira MG, Simplício H. Wrist immobilization after carpal tunnel release: a prospective study. Arquivos de Neuro-Psiquiatria 2006;64(3A):596-9. [PUBMED: 17119800]
Pomerance 2007 {published data only (unpublished sought but not used)}
  • Pomerance J, Fine I. Outcomes of carpal tunnel surgery with and without supervised postoperative therapy. Journal of Hand Surgery. American Volume 2007;32(8):1159-63. [PUBMED: 17923296]
Powell 2003 {unpublished data only}
  • Powell F. Desensitisation techniques: Do they reduce scar sensitivity following carpal tunnel release? (A pilot study). Unpublished Masters Thesis 2003.
Provinciali 2000 {published and unpublished data}
  • Giattini A, Logullo F, Morici D, Castellani G, Provinciali L. Physiotherapy reduced the recovery time after carpal tunnel syndrome. Neurorehabilitation and Neural Repair 1999;13(1):51.
  • Provinciali L, Giattini A, Splendiani G, Logullo F. Usefulness of hand rehabilitation after carpal tunnel surgery. Muscle and Nerve 2000;23(2):211-6. [PUBMED: 10639613]
Ritting 2012 {published data only (unpublished sought but not used)}
  • NCT01310218. Length of post operative dressing after carpal tunnel release. www.clinicaltrials.gov/show/NCT01310218 (accessed 15 November 2012). [ClinicalTrials.gov Identifier: NCT01310218]
  • Ritting AW, Leger R, O'Malley MP, Mogielnicki H, Tucker R, Rodner CM. Duration of postoperative dressing after mini-open carpal tunnel release: a prospective, randomized trial. Journal of Hand Surgery. American Volume 2012;37(1):3-8. [PUBMED: 22133704]
Stevinson 2003 {published data only (unpublished sought but not used)}
  • Stevinson C, Devaraj VS, Fountain-Barber A, Hawkins S, Ernst E. Homeopathic arnica for prevention of pain and bruising: randomized placebo-controlled trial in hand surgery. Journal of the Royal Society of Medicine 2003;96(2):60-5. [PUBMED: 12562974]
Williams 2008 {published and unpublished data}
  • Williams AM, Baker PA, Platt AJ. The impact of dressings on recovery from carpal tunnel decompression. Journal of Plastic, Reconstructive and Aesthetic Surgery 2008;61(12):1493-5. [PUBMED: 17983881]

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. References to studies awaiting assessment
  20. References to ongoing studies
  21. Additional references
Atherton 1999 {published data only}
  • Atherton WG, Faraj AA, Riddick AC, Davis TR. Follow-up after carpal tunnel decompression - general practitioner surgery or hand clinic? A randomised prospective study. Journal of Hand Surgery. British Volume 1999;24(3):296-7.
Cornesse 2010 {published data only}
  • Cornesse D, Senard M, Hans GA, Kirsch M, Hick C, Hallet C, et al. Comparison between two intraoperative intravenous loading doses on pain after minor hand surgery: two grams versus one gram. Acta Chirurgica Belgica 2010;110(5):529-32.
Gupta 2011 {published data only}
Heuser 2007 {published data only}
  • Heuser A, Kourtev H, Winter S, Fensterheim, Burdea G, Hentz V, et al. Telerehabilitation using the Rutgers Master II glove following carpal tunnel release surgery: proof-of-concept. IEEE Transactions of Neural Systems and Rehabilitation Engineering 2007;15(1):43-9.
Husby 2001 {published data only}
  • Husby T, Haugstvedt JR, Fyllingen G, Skoglund LA. Acute postoperative swelling after hand surgery: an exploratory, double blind, randomised study with paracetamol, naproxen and placebo. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery 2001;35(1):91-8.
Karamanis 2011 {published data only}
  • Karamanis N, Papanagiotoi M, Varitimidis S, Basdekis G, Stamatiou G, Dailiana Z, Malzios K. The effect of local anaesthetics in rehabilitation after open carpal tunnel release. Journal of Bone and Joint Surgery, British Volume 2011;93-B(SUPP II):219.
Ozer 2005 {published data only}
  • Ozer H, Solak S, Oguz T, Ocguder A, Colakoglu T, Babacan A. Alkalinisation of local anaesthetics prescribed for pain relief after surgical decompression of carpal tunnel syndrome. Journal of Orthopaedic Surgery 2005;13(3):285-9.
Romeo 2011 {published data only}

References to studies awaiting assessment

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. References to studies awaiting assessment
  20. References to ongoing studies
  21. Additional references
Chaise 1994 {published data only}
  • Chaise F, Guest M, Bellemère P, Friol JP, Gaisne E, Lehert P. The efficacy of naftidrofuryl on unexpected autonomic symptoms following carpal tunnel surgery. Annales de Chirurgie de la Main et du Membre Supérieur 1994;13(3):214-21.
Gordon 2007 {published data only (unpublished sought but not used)}
  • Gordon T, Brushart TM, Amirjani N, Chan KM. The potential of electrical stimulation to promote functional recovery after peripheral nerve injury - comparisons between rats and humans. Acta Neurochirurgica. Supplement 2007;100:3-11.
NCT00435149 {published data only}
  • NCT00435149. Post-operative mobilisation of carpal tunnel syndrome. http://clinicaltrials.gov/ct2/show/NCT00435149 (accessed 16 November 2012).

Additional references

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. References to studies awaiting assessment
  20. References to ongoing studies
  21. Additional references
AAOS 2007
  • American Academy of Orthopedic Surgeons. Clinical practice guideline on the diagnosis of carpal tunnel syndrome. www.aaos.org/research/guidelines/CTS_guideline.pdf 2007 (accessed 16 November 2012).
Agee 1992
  • Agee JM, McCarroll HR Jr, Tortosa RD, Berry DA. Szabo MR, Peimer CA. Endoscopic release of the carpal tunnel: a randomized prospective multicenter study. Journal of Hand Surgery. American Volume 1992;17(6):987-95.
Amick 2004
  • Amick BC 3rd, Habeck RV, Ossmann J, Fossel AH, Keller R, Katz JN. Predictors of successful work role functioning after carpal tunnel release surgery. Journal of Occupational and Environmental Medicine 2004;46(5):490-500.
Armstrong 2008
Aroori 2008
  • Aroori S, Spence RA. Carpal tunnel syndrome. Ulster Medical Journal 2008;77(1):6-17.
Atroshi 1999
Barcenilla 2012
Bland 2001
Braun 2002
Bromley 1994
Burt 2011
  • Burt S, Crombie K, Wurzelbacker S, Ramsey J, Deddens J. Workplace and individual risk factors for carpal tunnel syndrome. Journal of Occupational and Environmental Medicine 2000;68:928-33. [DOI: 10.1136/oem.2010.063677]
Chow 1989
  • Chow JCY. Endoscopic release of the carpal ligament: a new technique for carpal tunnel syndrome. Arthroscopy: The Journal of Arthroscopic and Related Surgery 1989;5(1):19-24. [DOI: 10.1016/0749-8063(89)90085-6]
Cowan 2012
  • Cowan J, Makanji H, Mudgal C, Jupiter J, Ring D. Determinants of return to work after carpal tunnel release. Journal of Hand Surgery 2012;37(A)(1):18-27.
Deeks 2011
  • Deeks JJ, Higgins JPT, Altmand DG. Analysing data and undertaking meta-analyses. In: Higgins JPT, Green S editor(s). Cochrane Handbook of Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011: Available from. www.cochrane-handbook.org, 2011.
DeStefano 1997
Dwan 2008
Dwan 2011
Finestone 1996
Gelberman 1998
  • Gelberman, et al. A scientific basis for clinical care. Orthopaedic Clinics of North America 1998;19:115-24.
Gelfman 2009
Geoghegan 2004
Gerritsen 2001
  • Gerritsen AAM, Uitdehaag BMJ, van Geldere D, Scholten RJPM, de Vet HCW, Bouter LM. Systematic review of randomized clinical trials of surgical treatment for carpal tunnel syndrome. British Journal of Surgery 2001;88(10):1285-95.
Giattini 1999
  • Giattini A, Logullo F, Morici D, Castellani G, Provinciali L. Physiotherapy reduced the recovery time after carpal tunnel syndrome. Neurorehabilitation and Neural Repair 1999;13(1):51. [DOI: 10.1177/154596839901300188]
Groves 1989
  • Groves EJ, Rider BA. A comparison of treatment approaches used after carpal tunnel release surgery. American Journal of Occupational Therapy 1989;43(6):398-402.
Hayes 2002
  • Hayes EP, Carney K, Wolf J, Smith JM, Akelman E. Carpal tunnel syndrome. In: Hunter JM, Mackin EJ, Callahan AD editor(s). Rehabilitation of the Hand and Upper Extremity. 5th Edition. St Louis: Mosby, 2002:643-59.
Herbert 2000
Higgins 2011
  • Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Review of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011.
Huisstede 2010
  • Huisstede BM, Randsdorp MS, Coert JH, Glerum S, van Middelkoop M, Koes BW. Carpal tunnel syndrome. Part II: effectiveness of surgical treatments - a systematic review. Archives of Physical Medicine and Rehabilitation 2010;91(7):1005-24.
Hunter 1991
Ibrahim 2012
  • Ibrahim I, Khan WS, Goddard N, Smitham P. Carpal tunnel syndrome: a review of the recent literature. Open Orthopaedics Journal 2012;6(Suppl 1: M8):69-76.
Idler 1996
  • Idler RS. Persistence of symptoms after surgical release of compressive neuropathies and subsequent management. Orthopedic Clinics of North America 1996;27(2):409-16.
Isaac 2010
  • Isaac S, Okoro T, Danial I, Wildin C. Does wrist immobilization following open carpal tunnel release improve functional outcome? A literature review. Current Reviews in Musculoskeletal Medicine 2010;3(1):11-7. [DOI: 10.1007/s12178-010-9060-9]
Jessurun 1988
  • Jessurun W, Hillen B, Huffstadt AJC. Carpal tunnel syndrome: postoperative care. Handchirurgie, Mikrochirurgie, Plastiche Chirurgie 1988;20(1):39-40.
Jüni 2001
Keilani 2002
  • Keilani MY, Crevenna R, Fialka-Moser V. Postoperative rehabilitation of patients with carpal tunnel syndrome. Wiener Medizinische Wochenschrift 2002;152(17-18):479-80.
    Direct Link:
Kim 2004
Kirkham 2010
  • Kirkham JJ, Dwan KM, Altman DG, Gamble C, Dodd S, Smyth R, et al. The impact of outcome reporting bias in randomised controlled trials on a cohort of systematic reviews. BMJ 2010;340:c365. [PUBMED: 20156912]
Lam 1998
Latinovic 2006
Louie 2012
  • Louie D, Earp B, Blazar P. Long-term outcomes of carpal tunnel release: a critical review of the literature. Hand 2012 June 22;Online:1-5. [DOI: 10.1007/s11552-012-9429-x]
Marshall 2007
Nathan 1993
  • Nathan PA, Meadows KD, Keniston RC. Rehabilitation of carpal tunnel surgery patients using a short surgical incision and an early program of physical therapy. Journal of Hand Surgery. American Volume 1993;18(6):1044-50.
O'Connor 2003
  • O'Connor D, Daborn C. Rehabilitation treatments following carpal tunnel surgery. Cochrane Database of Systematic Reviews 2003, Issue 2. [DOI: 10.1002/14651858.CD004158]
O'Connor 2012
Odgaard-Jensen 2011
Page 2012a
  • Page MJ, O'Connor D, Pitt V, Massy-Westropp N. Therapeutic ultrasound for carpal tunnel syndrome. Cochrane Database of Systematic Reviews 2012, Issue 1. [DOI: 10.1002/14651858.CD009601]
Page 2012b
  • Page MJ, O’Connor D, Pitt V, Massy-Westropp N. Exercise and mobilisation interventions for carpal tunnel syndrome. Cochrane Database of Systematic Reviews 2012, Issue 6. [DOI: 10.1002/14651858.CD009899]
Page 2012c
  • Page MJ, Massy-Westropp N, O'Connor D, Pitt V. Splinting for carpal tunnel syndrome. Cochrane Database of Systematic Reviews 2012, Issue 7. [DOI: 10.1002/14651858.CD010003]
Palmer 2007
Phalen 1966
  • Phalen GS. The carpal tunnel syndrome. Seventeen years' experience in diagnosis and treatment of six hundred and fifty-four hands. Journal of Bone and Joint Surgery 1966;48(2):211-28.
Rempel 1998
  • Rempel D, Evanoff B, Amadio PC, de Krom M, Franklin G, Franzblau A, et al. Consensus criteria for the classification of carpal tunnel syndrome in epidemiologic studies. American Journal of Public Health 1998;88(10):1447-51.
RevMan 2012
  • The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). 5.2. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2012.
Sanati 2011
  • Sanati KA, Mansouri M, Macdonald D, Ghafghazi S, Macdonald E, Yadegarfar G. Surgical techniques and return to work following carpal tunnel release: a systematic review and meta-analysis. Journal of Occupational Rehabilitation 2011;21(4):474-81.
Scholten 2007
  • Scholten RJPM, Mink van der Molen A, Uitdehaag BMJ, Bouter LM, de Vet HCW. Surgical treatment options for carpal tunnel syndrome. Cochrane Database of Systematic Reviews 2007, Issue 4. [DOI: 10.1002/14651858.CD003905.pub3]
Skirven 1994
Stanek 1996
  • Stanek EJ 3rd, Pransky G. Unilateral vs. bilateral carpal tunnel: challenges and approaches. American Journal of Industrial Medicine 1996;29(6):669-78.
Stapleton 2006
Sterne 2011
  • Sterne JAC, Egger M, Moher D. Addressing reporting biases. In: Higgins JPT, Green S editor(s). Cochrane Handbook of Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011: Available www.cochrane-handbook.org.
Stevens 1997
Szabo 1994
  • Szabo RM, Steinberg DR. Nerve entrapment syndromes in the wrist. Journal of the American Academy of Orthopedic Surgeons 1994;2(2):115-23.
Van Rijn 2009
  • Van Rijn RM, Huisstede BMA, Koes BW, Burdorf A. Associations between work-related factors and the carpal tunnel syndrome-a systematic review. Scandinavian Journal of Work, Environment and Health 2009;35(1):19-36.
Verdugo 2008
Wilson 2003
Wood 2008
  • Wood l, Egger M, Gluud LL, Schulz KF, Jüni P, Altman DG, et al. Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: meta-epidemiological study. BMJ 2008;336(7644):601-5.
Wyatt 2012
Zanette 2010
  • Zanette G, Cacciatori C, Tamburin S. Central sensitization in carpal tunnel syndrome with extraterritorial spread of sensory symptoms. Pain 2010;148(2):227-36.