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Therapeutic ultrasound for carpal tunnel syndrome

  1. Matthew J Page1,*,
  2. Denise O'Connor1,
  3. Veronica Pitt2,
  4. Nicola Massy-Westropp3

Editorial Group: Cochrane Neuromuscular Group

Published Online: 28 MAR 2013

Assessed as up-to-date: 27 NOV 2012

DOI: 10.1002/14651858.CD009601.pub2


How to Cite

Page MJ, O'Connor D, Pitt V, Massy-Westropp N. Therapeutic ultrasound for carpal tunnel syndrome. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD009601. DOI: 10.1002/14651858.CD009601.pub2.

Author Information

  1. 1

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

  2. 2

    National Trauma Research Institute, The Alfred Hospital, Monash University, Melbourne, Victoria, Australia

  3. 3

    University of South Australia, Health Sciences, Adelaide, South Australia, Australia

*Matthew J Page, School of Public Health & Preventive Medicine, Monash University, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004, Australia. matthew.page@monash.edu.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 28 MAR 2013

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Characteristics of included studies [ordered by study ID]
Bakhtiary 2004

MethodsRandomised controlled trial

No blinding reported by authors

Randomisation occurred at the level of wrists, where participants with bilateral CTS received a different intervention for each wrist


ParticipantsTotal n = 50 (90 wrists) randomised

Intervention group n = 45 wrists

Control group n = 45 wrists

Sex not reported

Mean ± SD age:

Intervention group: 45 ± 17.1 yrs

Control group: 48 ± 13.4 yrs

Mean ± SD duration of CTS symptoms*

Intervention group: 7.1 ±  6.9 months

Control group: 6.7 ±  6.5 months

Inclusion criteria:

1. Numbness in the median nerve distribution and night waking lasting more than one month

2. Positive Phalen’s test.

3. Positive Tinel’s test.

4. Participants had to fulfil standard electrophysiological criteria including prolongation of nerve conduction velocity (i.e. motor latency > 4 ms or sensory latency > 3.5 ms). 

Exclusion criteria:

1. Secondary entrapment neuropathies

2. Electroneurographic and clinical signs of axonal degeneration of the median nerve

3. Treated with ultrasound or low level laser therapy for the syndrome

4. Required regular analgesic or anti-inflammatory drugs

5. History of steroid injection into the carpal tunnel, thyroid disease, diabetes, or systemic peripheral neuropathy


InterventionsIntervention: Ultrasound treatment was administered for 15 minutes per session to the area over the carpal tunnel at a frequency of 1 MHz and an intensity of 1.0 W/cm2, with pulsed mode duty cycle of 1:4 and a transducer area of 5 cm2, using an Enraf Sonopuls 434 machine with aquasonic gel as the couplant. The apparatus was initially standard and the output was controlled regularly by a simple under-water radiation balance. A total of 15 ultrasound treatments were performed once a day, five times a week for three weeks.

Control: Low-level laser therapy was administered by applying a low intensity (9 J), infrared laser diode (Enraf, Endolaser 830 nm) at five points (1.8 J/point) over the course of the median nerve at the wrist. The output of the laser beam was controlled each session by a simple infrared photocell. A total of 15 laser therapies were performed once a day, 5 times a week for 3 weeks.


OutcomesOutcomes assessed at baseline, at the end of three weeks treatment, and 4 weeks after treatment ended (7 weeks from baseline):

1. Pain using a zero to 10 VAS**

2. Pinch strength (N) using with a standard dynamometer between the tips of the thumb and the little finger**

3. Hand grip strength (N) using a handheld dynamometer: average force of three consecutive trials was calculated**

4. Nerve conduction: median motor distal latency (msec), median sensory distal latency (msec), compound muscle action potential amplitude (mV), sensory action potential amplitude (uV)**


Notes*Measured as 'duration of current main complaints (months)'

**Data reported only as change from baseline scores (no endpoint data reported).

Analysis was undertaken at the wrist level for all outcomes, though some participants in each group had bilateral CTS. Bilateral cases had a different intervention applied to each wrist. The trialists did not report in the publication how the correlation between both wrists was accounted for in the analysis, and when contacted, confirmed that no such method was used. Therefore, a unit of analysis error is likely to have occurred. No attempt was made to adjust outcome data.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "As there were two categories of carpal tunnel syndrome patients, patients with bilateral involvement (n = 40), and patients with unilateral involvement (n = 10), a computer generated randomisation list was drawn up by the statistician for each category...Thus patients with both wrists affected were assigned randomly to one of the two following treatment groups: Group A, who received ultrasound in the right hand and low level laser therapy in the left hand; or Group B, who received low level laser therapy in the right hand and ultrasound in the left hand. The patients with one wrist affected were also assigned randomly to the following treatment groups: Group C, who received ultrasound treatment; and Group D, who received low level laser therapy treatment."

Comment: The allocation sequence was probably adequately generated.

Allocation concealment (selection bias)Unclear riskQuote: "....a computer generated randomisation list was drawn up by the statistician for each category. It was given to the physiotherapy department in two sets of sealed numbered envelopes, one set for bilateral carpal tunnel syndrome patients and one set for unilateral carpal tunnel syndrome patients. When the patients qualified to enter the study and had signed informed consent, according to their bilateral or unilateral involvement the appropriate numbered envelope was opened at the reception; the card inside indicated the patient's allocation to a treatment group. This information was then given to the physiotherapist to administer appropriate intervention."

Comment: It is not clear whether the sealed numbered envelopes were opaque and sequentially numbered, therefore it is not clear whether the allocation sequence was adequately concealed until interventions were assigned.

Blinding of participants and personnel (performance bias)
Self-reported outcomes
Unclear riskComment: While unclear, participants are unlikely to have been blinded to which treatment they received, as there was no report that, for example, they were blindfolded to which wrist was receiving which treatment.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "The staff who assessed the outcomes were different from the staff administering the treatments, and they were blinded to the type of treatment (low level laser therapy or ultrasound) each patient had received."

Comment: Staff administering the treatments are unlikely to have been blinded, but outcome assessors of objectively-measured outcomes were likely to have been blinded successfully.

Incomplete outcome data (attrition bias)
3 months or less
Low riskQuote: "In order to reduce the number lost to follow-up, we guaranteed to complete the treatment regimen with more effective treatments if there was no benefit from the applied treatment at the end of the study. Thus, all patients completed the study to the end of the four-week follow up period."

Comment: Outcome data are likely to be complete

Selective reporting (reporting bias)Low riskComment: All outcomes stated in the methods section of the publication were reported in the results in their pre-specified way.

Other biasLow riskComment: No other sources of bias identified.

Baysal 2006

MethodsRandomised single-blind controlled trial

Blinded outcome assessors

Randomisation occurred at the level of participants, not wrists (i.e. participants with bilateral CTS received the same intervention for both wrists)


ParticipantsTotal n = 36 (72 wrists) randomised

Intervention group 1 n = 12 (24 wrists) randomised; 12 (24 wrists) completed

Intervention group 2 n = 12 (24 wrists) randomised; 8 (16 wrists) completed

Intervention group 3 n = 12 (24 wrists) randomised; 8 (16 wrists) completed

0 males, 36 females

Mean ± SD age:

Intervention group 1: 47.8 ± 5.5 yrs

Intervention group 2: 50.1 ± 7.3 yrs

Intervention group 3: 51.4 ± 5.2 yrs

Mean± SD duration of CTS symptoms:

Intervention group 1: 1.5 ± 1.6 yrs

Intervention group 2: 1.4 ± 0.8 yrs

Intervention group 3: 1.4 ± 0.8 yrs

Inclusion criteria:

1. Subjectively reported history of paraesthesia or pain in the median nerve distribution, nocturnal pain, and dysaesthesia

2. Tinel’s test, Phalen’s test, pain measurement, two-point discrimination test, and grip and pinch strength measurement (no information provided on which criteria for these physician-assessed outcomes had to be fulfilled by participants)

Exclusion criteria:

1. Secondary entrapment neuropathies

2. Treated with ultrasound for CTS

3. Required regular analgesic or anti-inflammatory drugs.

4. Clinical sign for axonal degeneration of the median nerve (thenar atrophy) on electromyographic examination of the abductor pollicis brevis muscle

5. Evidence of denervation (abnormal spontaneous activity in the form of fibrillations and positive sharp waves) on electromyographic examination of the abductor pollicis brevis muscle

6. History of steroid injection into the carpal tunnel, thyroid disease, diabetes, systemic peripheral neuropathy, pregnancy, or splint use


InterventionsIntervention group 1: Splinting and exercise therapy 

Intervention group 2: Splinting and ultrasound therapy

Intervention group 3: Splinting, exercise, and ultrasound therapy

(No description of how these combinations of treatments were completed by participants over the three week treatment period)

Splinting - A custom-made neutral volar splint was given to patients. The patients were instructed to wear the splints all night and during the day for 3 weeks.

Ultrasound therapy - Ultrasound treatment was administered 15 min per session to the palmar carpal tunnel area at a frequency of 1 MHz and intensity of 1.0 W/cm2, pulsed mode 1 : 4, with a transducer of 5 cm2 (Electronica Pagani FP-942/S) and with aquasonic gel as the couplant. The apparatus was standardized initially, and the output was controlled regularly by a simple underwater radiation balance. A total of 15 ultrasound treatments were performed once a day, five times a week, for 3 weeks.

Exercise therapy - Participants were instructed to perform nerve-and tendon gliding exercises developed by Totten and Hunter. Brochures describing exercises were also given to patients.The exercises were applied as five sessions daily. Each exercise was repeated 10 times at each session. Exercise treatment was continued for 3 weeks.


OutcomesOutcomes assessed at the first treatment session, at the end of therapy, and 8 weeks after treatment ended (11 weeks from baseline):*

1. Pain using a visual scale (VAS), on which the patients could indicate their assessment along a distance of 10 cm, ranging from 0 (no pain at all) to 10 (the most intense pain that I can imagine)*

2. Tinel's sign (rated as positive or not)

3. Phalen's sign (rated as positive or not)

4. Two-point discrimination: performed on the pulp of the three radial digits

5. Symptoms using carpal tunnel questionnaire (rates 11 items on ordinal scale 1: mildest, to 5: most severe)* (Levine 1993)

6. Hand function using carpal tunnel questionnaire (rates 8 items on ordinal scale 1: no difficulty with the activity, to 5: cannot perform the activity at all)* (Levine 1993)

7. Hand grip strength using a handheld dynamometer: average force of three consecutive trials calculated*

8. Pinch grip strength using a standard dynamometer between the tips of the thumb and the little finger: average force of three consecutive trials calculated*

9. Nerve conduction: Median motor distal latency (msec), and sensory distal latency (msec)*

10. Satisfaction using a question asked over the telephone: rated as excellent if a patient is asymptomatic, good: rarely symptomatic, fair: symptomatic only during compelling activity or poor: continuing symptoms (without relief following treatment) (only measured at the final follow-up). Authors report that patients' satisfaction investigation was performed at an average of 11 ± 4.5 months


Notes*Endpoint scores for all outcomes were reported in the trial publication. Change from baseline scores were reported for these outcomes only if the difference between time points was statistically significant (P < 0.05). As the risk of outcome reporting bias was high for these change from baseline scores, endpoint scores (which were completely reported) were entered in RevMan.

Analysis was undertaken at the wrist level for all outcomes, though all participants in each group had bilateral CTS. Bilateral cases had the same intervention applied to each wrist. The trialists did not report how the correlation between both wrists was accounted for in the analysis, and attempts to clarify this information from the trialists were unsuccessful. Therefore, it is not clear whether a unit of analysis error occurred. No attempt was made to adjust outcome data.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Computer-generated randomization list was created by a biostatistician."

Comment: The allocation sequence was probably adequately generated.

Allocation concealment (selection bias)Unclear riskQuote: "Computer-generated randomization list was created by a biostatistician. It was given to the physiotherapy department in sealed numbered envelopes. When the patients qualified to enter the study, appropriate numbered envelope was opened at the reception; the card inside indicated the patient's allocation to a treatment group."  Comment: It is not clear whether the sealed numbered envelopes were opaque and sequentially numbered, therefore it is not clear whether the allocation sequence was adequately concealed until interventions were assigned.

Blinding of participants and personnel (performance bias)
Self-reported outcomes
High riskComment: Not reported, and given the nature of the intervention it is unlikely that participants were not aware of which group they were assigned to.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "The staff who assessed the outcomes were different from the staff administering the treatments and were blinded to the type of treatment each patient had received."

Comment: Outcome assessors of objectively measured outcomes were probably blinded to treatment assignment.

Incomplete outcome data (attrition bias)
3 months or less
Low riskQuote: Twenty-eight patients (56 wrists) completed the study. The eight dropouts are described as follows: two patients (group II) underwent surgery, two patients (group II) were lost to follow-up. In group III, two patients were lost to follow-up, and another two patients (group III) refused electrophysiologic study due to improvement of symptoms."

Comment: The eight randomised participants who were drop-outs and losses to follow-up were clearly described,

Incomplete outcome data (attrition bias)
After 3 months
High riskComment: There is no explanation for why results of the patient satisfaction questionnaire is based on fewer than 28 participants with 56 wrists.

Selective reporting (reporting bias)Low riskComment: All outcomes were fully reported as endpoint scores at the end of treatment and at eight weeks follow-up. The authors also reported change from baseline scores for some (not all) of the outcomes, but numerical data suitable for inclusion in a meta-analysis were only reported if the effect estimate was statistically significant. For non-significant effects, the authors only reported that the result was "NS". Given endpoint scores were available and no meta-analysis was performed, this selective reporting of data is unlikely to affect the results.

Other biasLow riskComment: No other sources of bias identified.

Bilgici 2010

MethodsStudy design: Randomised controlled trial

It is unclear whether randomisation occurred at the level of participants or wrists, and whether all bilateral CTS participants received the same or different intervention for each wrist


ParticipantsDetails of sampling frame:

Total N randomised = 34 participants (49 wrists) randomised; 31 participants (45 wrists) completed

Intervention group 1 N = 16 participants (24 wrists) randomised; 15 participants (23 wrists) completed

Intervention group 2 N = 18 participants (25 wrists) randomised; 16 participants (22 wrists) completed

Group 1: 5 males; 10 females

Group 2: 4 males; 12 females

Group-specific sex only reported for participants who completed trial. Overall 24 women and 10 men were randomised

Mean ± SD (range) age:

Group 1: 47.33 ± 7.44

Group 2: 44.15 ± 9.30

Group-specific age only reported for participants who completed trial

Mean ± SD (range) duration of CTS symptoms:

Group 1: 46.33 ± 34.04 months

Group 2: 46.29 ± 61.36 months

Group-specific duration of symptoms only reported for participants who completed trial

Inclusion criteria:

1. Had clinical symptoms and signs of CTS confirmed by standard electrodiagnosis, with no abnormalities in the radial or ulnar nerve.

Exclusion criteria:

1. Had thenar atrophy or spontaneous activity (fibrillation potentials and positive sharp waves) on electromyographic examination of the abductor pollicis brevis muscle

2. Pregnant

3. Had previous wrist trauma

4. Had a history of steroid injection into the carpal tunnel

5. Had rheumatic diseases

6. Had cervical radiculopathy

7. Had diabetes or other pathologic conditions predisposing to peripheral neuropathies


InterventionsGroup 1: Ultrasound treatment delivered under water at a frequency of 3MHz and with an intensity of 1.5W/cm2 for five minutes, five times per week for four weeks.

Group 2: Local corticosteroid injection plus neutral-positioned wrist splint worn as much as possible during the day and night for four weeks. Local corticosteroid injection was given using a 22-gauge needle at the proximal part of the carpal tunnel to the wrist crease just medial to the tendons of the flexor radial muscle involving a single 4mg dexamethasone injection without lidocaine


OutcomesOutcomes assessed at baseline, at the end of the four week treatment period, and at four weeks post-treatment.

1. Symptoms using the Turkish-translated Boston Carpal Tunnel Questionnaire, calculated as the mean of 11 items scored from 1 (mildest) to 5 (most severe) (Levine 1993)

2. Pain using a VAS

3. Function using the Turkish-translated Boston Carpal Tunnel Questionnaire, calculated as the mean of eight items scored from 1 (no difficulty in the activity to 5 (cannot perform the activity at all) (Levine 1993)

4. Grip strength measured using a hand-held dynamometer, where the participants positioning was standardised and the average force of three consecutive trials was calculated

5. Two-point discrimination performed on the pulp of three radial digits and the mean recorded (not an outcome of interest to the review)

6. Nerve conduction: median nerve motor distal latency (msec), median sensory nerve conduction velocity (m/sec)

7. Adverse effects


NotesAnalysis was undertaken at the wrist level for all outcomes, though some participants in each group had bilateral CTS. It is not clear whether bilateral CTS participants received the same intervention for both wrists. The trialists did not report how the correlation between both wrists was accounted for in the analysis, and attempts to clarify this information from the trialists were unsuccessful. Therefore, it is not clear whether a unit of analysis error occurred. No attempt was made to adjust outcome data.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "The randomization was performed by using sequentially numbered and sealed opaque envelopes. Following the baseline assessment, patients were randomised to either ultrasound treatment (group A) or local corticosteroid injection plus splinting (group B)."
Comment: No information on how the random sequence was generated was provided.

Allocation concealment (selection bias)Low riskQuote: "The randomization was performed by using sequentially numbered and sealed opaque envelopes. Following the baseline assessment, patients were randomised to either ultrasound treatment (group A) or local corticosteroid injection plus splinting (group B)."
Comment: The allocation sequence was probably adequately generated.

Blinding of participants and personnel (performance bias)
Self-reported outcomes
High riskComment: Due to the nature of the interventions delivered (ultrasound versus splint plus corticosteroid injection), it is unlikely that participants and personnel were unaware of treatment allocation

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskQuote: "All patients were examined by the same physician".
Comment: The authors did not report whether the outcome assessor of objective outcomes was blind to treatment allocation

Incomplete outcome data (attrition bias)
3 months or less
Low riskQuote: "A total of 49 hands of 34 patients (24 women and 10 men) were enrolled in this study. 16 patients were randomly assigned to the group A, and 18 patients were randomly assigned to the group B. Three patients did not complete the 8 week follow-up. One patient in group B did not allow to be injected into her hand after randomization. Two patients (one in each group), could not be reached and were lost to follow-up. They were excluded from the study and data analysis. Thus, 15 patients (23 hands) in the Group A, and 16 patients (22 hands) in the Group B completed the follow-up at 8 weeks".
Quote: "The per-protocol analyses included 45 hands".
Comment: The overall amount of attrition, and reasons for this is small and relatively similar across groups, and unlikely to have affected the results of outcomes.

Selective reporting (reporting bias)Low riskComment: All outcomes specified in the Methods section were reported in the Results section in sufficient detail to be included in a meta-analysis.

Other biasLow riskComment: No other sources of bias identified.

Dincer 2009

MethodsRandomised controlled trial

Blinded outcome assessors

Randomisation occurred at the level of participants, not wrists (i.e. participants with bilateral CTS received the same intervention for both wrists)


ParticipantsTotal n = 60 (120 wrists) randomised
Intervention group 1 n = 40 wrists randomised; 34 wrists completed
Intervention group 2 n = 40 wrists randomised; 30 wrists completed

Intervention group 3 n = 40 wrists randomised; 36 wrists completed

0 males; 60 females

Mean ± SD age*:
Intervention group 1 51.8 ± 6.6 yrs
Intervention group 2 49.7 ± 9.5 yrs

Intervention group 3 52.2 ± 9.1 yrs

Inclusion criteria:
1. Diagnosed with mild to moderate CTS according to the American Association of Electrodiagnostic Medicine guidelines

Exclusion criteria:
1. Diagnosed with severe CTS according to the American Association of Electrodiagnostic Medicine guidelines
2. Underlying metabolic disorders such as diabetes mellitus, thyroid or kidney disease
3. Connective tissue disorders
4. Malignancy
5. Distal radial fracture
6. Cervical radiculopathy
7. Brachial plexopathy
8. Tenosynovitis

9. Fibromyalgia

10. Any other CTS treatment or surgical procedure during the past year

11. Pregnant


InterventionsIntervention group 1: Neutral standard light-weight wrist splint worn at night and during aggravating daytime activities for three months

Intervention group 2: Neutral standard light-weight wrist splint worn at night and during aggravating activities for three months plus ultrasound therapy administered to each hand for 3 minutes per session, with 10 sessions performed once a day, five times a week for two weeks. Ultrasound was administered at a frequency of 3 MHz and an intensity of 1.0 W/cm2 in a continuous mode

Intervention group 3: Neutral standard light-weight wrist splint worn at night and during aggravating activities for three months plus low-level laser therapy applied to three points over the course of the median nerve for 30 seconds at each point, with 10 sessions performed once a day, five times a week for two weeks. An infrared GaAs diode laser with a wavelength of 904 nm, frequency range of 5-7000 Hz, pulse duration of 200 nsec, maximum power output of 27 W, average power of 2.4 mW, and spot size of 0.07cm2 was used.


OutcomesOutcome assessed at baseline, one month and three months after end of treatment

1. Pain using zero to 10 VAS (0 = "no pain", 10 = "the most intense pain one can imagine")
2. Symptoms using Boston carpal tunnel questionnaire (rates 11 items on ordinal scale 1: no symptom, to 5: the most severe symptom) (Levine 1993)
3. Function using Boston carpal tunnel questionnaire (rates 8 items on ordinal scale 1: no symptom, to 5: the most severe symptom) (Levine 1993)
4. Patient satisfaction measured using a five point scale, including "completely satisfied", "almost satisfied", "moderately satisfied", "somewhat satisfied", and "dissatisfied"**
5. Nerve conduction***: median nerve motor distal latency, median nerve motor conduction velocity, compound muscle action potential at the wrist and elbows, second digit-wrist median nerve sensory velocity


Notes*The authors reported the age of randomised participants, not those who completed the study

**The authors dichotomised this outcome into "satisfied" (based on rating either "almost satisfied" or "completely satisfied") or not

***The authors reported an outcome, "number of completely normal hands according to electroneuromyography at 3 months", but did not report what the specific criteria for "completely normal"

Analysis was undertaken at the wrist level for all outcomes, though all participants in each group had bilateral CTS. Bilateral cases had the same intervention applied to each wrist. The trialists did not report how the correlation between both wrists was accounted for in the analysis, and attempts to clarify this information from the trialists were unsuccessful. Therefore, it is not clear whether a unit of analysis error occurred. No attempt was made to adjust outcome data.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "Randomization was performed by the use of numbered envelopes".

Comment: Not clear how, and whether or not, the randomisation sequence was adequately generated.

Allocation concealment (selection bias)Unclear riskQuote: "Randomization was performed by the use of numbered envelopes".

Comment: Not clear whether the allocation sequence was adequately concealed (i.e. whether the numbered envelopes were sealed and opaque and sequentially numbered).

Blinding of participants and personnel (performance bias)
Self-reported outcomes
High riskQuote: "Ultrasound therapy was administered to each hand for 3 min per session, on the area over the carpal tunnel…with aquasonic gel.

Quote: "Laser therapy was applied to three points over the course of the median nerve at the wrist. The laser probe was applied directly and perpendicularly in contact with the skin for 30 sec at each point..At each treatment session, the patients and physiotherapist wore protective glasses."

Comment: It is possible participants were aware of treatment allocation based on the different treatment modalities delivered.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "At the beginning, all of the patients were assessed by the same physiatrist (E.C.) and at the first and third month the assessments were performed by another physiatrist who was blinded to treatment modality (M.Z.K.). Electrodiagnostic evaluations were performed by another physiatrist (U.D.)

Comment: Blinding of outcome assessors was probably done.

Incomplete outcome data (attrition bias)
3 months or less
Low riskQuote: "A total of 60 females patients with bilateral mild to moderate CTS (120 hands) were included in this study and randomised into three groups (40 hands in each group). Four patients did not finish therapy and six patients did not come to follow-up assessments, thus the study was completed with a total of 100 hands; 34 in the Sp group, 30 in the SpUS group, and 36 hands in the SpLLL group"

Comment: The number of drop-outs in each group was clearly reported, was small, and relatively similar across groups.

Selective reporting (reporting bias)High riskComment: The authors reported in the Methods section that median nerve motor distal latency, median nerve motor conduction velocity, compound muscle action potential at the wrist and elbows, and median nerve sensory velocity were measured, however only reported the results in numerical format suitable for meta-analysis for the outcomes median nerve motor distal latency and second digit-wrist median nerve sensory velocity. Further, the authors reported a new outcome in the Results section, "number of completely normal hands based on electroneuromyography at 3 months", but did not report how "completely normal" was defined in the Methods section.

Other biasLow riskComment: No other sources of bias identified.

Duymaz 2012

MethodsRandomised double-blind controlled trial

Blinded participants (only for two of the three groups) and outcome assessors (only for neurophysiologic parameters)


ParticipantsTotal n = 58 (58 wrists) randomised

Intervention group 1 n = 20 (20 wrists) randomised and completed

Intervention group 2 n = 20 (20 wrists) randomised and completed

Intervention group 3 n = 18 (28 wrists) randomised and completed

Intervention group 1: 1 male, 19 females

Intervention group 2: 2 males, 18 females

Intervention group 3: 0 males, 18 females

Mean ± SD age:

Intervention group 1: 51.25 ± 6.88 yrs

Intervention group 2: 51.5 ± 8.08 yrs

Intervention group 3: 53.7 ± 8.35 yrs

Mean ± SD duration of CTS symptoms: Not reported

Inclusion criteria:

1. Diagnosis of idiopathic CTS based on provocation tests and electromyography during examination and complaints of numbness, tingling, weakness and pain in the hands lasting at least three months

Exclusion criteria:

1. Presence of symptoms for more than a year

2. Acute findings

3. History of steroid injections or physical therapy

4. Systemic disease

5. Two-point discrimination distance of greater than 6 mm

6. Presence of thenar atrophy, more proximal complex neuropathy, cervical discopathy, cervical Da Costa’s syndrome, shoulder, elbow, wrist, or finger problems (frozen shoulder, epicondylitis, cubital tunnel syndrome, history of wrist fracture, trigger finger)

7. Presence of a pacemaker

8. Other etiological causes leading to CTS, e.g. rheumatoid arthritis, gout, pregnancy

9. Previous CTS surgery


InterventionsIntervention group 1: Therapeutic ultrasound (for 5 min per session, once a day 5 times a week for 3 weeks; intensity was 0.8 W/cm2, and frequency was 1 MHz) plus 3 sets of 10 nerve and tendon gliding exercises performed every day plus neutral wrist splint worn every night plus activity modification training.

Intervention group 2: Dexamethasone iontophoresis (dexamethasone sodium diphosphonate 0.4% solution was poured in the activated carbon electrode pad of 25cm2 placed over the carpal tunnel, and administration was performed by applying a current of 2 mA for 20 minutes) plus three sets of 10 nerve and tendon gliding exercises performed every day plus neutral wrist splint worn every night plus activity modification training.

Intervention group 3: Placebo iontophoresis (water was poured in the activated carbon electrode pad of 25cm2 placed over the carpal tunnel, and administration was performed by applying a current of 2 mA for 20 minutes) plus three sets of 10 nerve and tendon gliding exercises performed every day plus neutral wrist splint worn every night plus activity modification training.


OutcomesOutcome assessed at the end of 3 weeks treatment and 3 months after the end of treatment

1. Pain on movement, pain at rest, and pain at night, using a VAS*

2. Symptoms using Boston carpal tunnel questionnaire (BCTQ) (rates 11 items on ordinal scale 1: no symptom, to 5: the most severe symptom) (Levine 1993)
3. Function using Boston carpal tunnel questionnaire (BCTQ) (rates 8 items on ordinal scale 1: no symptom, to 5: the most severe symptom) (Levine 1993)

4. Function using the Health Assessment Questionnaire

5. Wrist flexion/extension range of motion (not an outcome of interest to the review)

6. Muscle test for the muscles in the carpal tunnel region and the abductor pollicis brevis (using the five points scale) (not an outcome of interest to the review)

7. Grip strength**

8. Pinch strength**

9. Two-point discrimination (not an outcome of interest to the review)

10. Sensation using the Semmes-Weinstein monofilaments (not an outcome of interest to the review)

11. Phalen's test**

12. Reverse Phalen's test**

13. Tinel's test**

14. Carpal compression test**

15. Neurophysiological parameters (sensory nerve distal latency, sensory nerve amplitude, sensory nerve conduction velocity, motor nerve distal latency, motor nerve amplitude, motor nerve conduction velocity, compound muscle action potential of the abductor pollicis brevis muscle)****


Notes*Trialists reported outcome data for change from baseline to end of treatment and change from end of treatment to three months follow-up. We only extracted the change from baseline to end of treatment values.

**No outcome data sufficient for entry into RevMan was reported in the study publication.

***Trialists reported means and SDs for each of the six neurophysiologic parameters, but it is not clear whether the data are endpoint values at end of treatment, endpoint values at three months follow-up, change from baseline to end of treatment values, or change from baseline to three months follow-up values. For this reason, we did not extract the mean (SD) outcome data reported for any the six neurophysiologic parameters.

All participants contributed only one CTS-affected wrist to the study. Therefore, a unit of analysis error resulting from the correlation between two wrists in bilateral CTS participants could not have occurred.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "The patients were randomly divided into three groups using computer-generated random numbers."

Allocation concealment (selection bias)Unclear riskQuote: "The patients were randomly divided into three groups using computer-generated random numbers. After the examination of each patient, the physician sent the number in an envelope to the physiotherapist."

Comment: Trialists did not report whether the envelopes were sequentially numbered, sealed, and opaque, so it is unclear whether all essential safeguards to conceal the allocation sequence were utilised.

Blinding of participants and personnel (performance bias)
Self-reported outcomes
High riskQuote: "The persons’ who performed the statistical analysis and electrophysiological assessment was blind to the therapy as were the patients who received dexamethasone iontophoresis or sham iontophoresis."

Comment: Participants and personnel delivering ultrasound were not blind to treatment.

Blinding of outcome assessment (detection bias)
All outcomes
High riskQuote: "The persons’ who performed the statistical analysis and electrophysiological assessment was blind to the therapy as were the patients who received dexamethasone iontophoresis or sham iontophoresis."

Comment: The only outcome assessed by a blinded assessor was neurophysiological parameters. Other objective outcomes (e.g. grip strength) and self-reported outcomes were assessed by unblinded assessors.

Incomplete outcome data (attrition bias)
3 months or less
Low riskComment: No drop-outs, losses to follow-up or exclusions were reported,

Selective reporting (reporting bias)High riskComment: Outcome data was not fully reported for all outcomes. For some outcomes (e.g. Phalen's test, grip strength, pinch strength), trialists only reported whether the differences between groups were statistically significant or not. For other outcomes (e.g. wrist extension and flexion range of motion), no information about the results was reported.

Other biasLow riskComment: No other sources of bias identified.

Ebenbichler 1998

MethodsRandomised, triple-blind, placebo-controlled trial

Blinded participants, personnel and outcome assessors

Randomisation occurred at the level of wrists, where participants with bilateral CTS received a different intervention for each wrist


ParticipantsTotal n = 45 (90 wrists) randomised
Intervention group n = 45 (45 wrists)
Control group n = 45 (45 wrists)

Sex not reported

Mean ± SD age: 51 ± 15 yrs

Inclusion criteria:
1. Bilateral idiopathic CTS confirmed with electrodiagnostic testing
2. Mild to moderate pain lasting longer than 3 months
3. Informed written consent

Exclusion criteria:
1. Secondary entrapment neuropathies
2. Systemic disease
3. Electroneurographic and clinical signs of median nerve axonal degeneration
4. Previous CTR
5. Previous ultrasound treatment
6. History of steroid injection into carpal tunnel
7. Regular analgesic or anti-inflammatory drug requirements


InterventionsIntervention: Pulsed ultrasound therapy using 1.0 W/cm2 intensity and 1 MHz frequency, 15 minute session daily, 5 times a week for 2 weeks, followed by twice a week for 5 weeks

Control: Placebo ultrasound therapy using 0.0 W/cm2 intensity, 15 minute session daily, 5 times a week for 2 weeks, followed by twice a week for 5 weeks


OutcomesOutcome assessed at 2 weeks (after 10 sessions), 7 weeks (at end of treatment) and 6 months after end of treatment

1. Symptoms using zero to 10 VAS (0 = "no complaints at all", 10 = "the most intense complaints I can imagine")
2. General symptom improvement (ordinal scale 1 = free of symptoms, 5 = much worse) (at 7 weeks and 6 months only)
3. Sensation using sharp pin wheel and VAS.
4. Grip strength in kilograms using Preston dynamometer
5. Pinch strength in kilograms using Preston dynamometer
6. Nerve conduction: median distal motor latency, sensory nerve action potentials*, sensory nerve conduction velocity, median motor nerve conduction velocity*

7. Medication use

8. Adverse effects

9. Return to work (selectively reported)


Notes*No data reported

Sex of participants not reported

Mean and SD endpoint values for symptoms, sensation, grip strength, pinch strength and nerve conduction outcomes were provided by authors to facilitate entry into RevMan, as data were reported in the publication as mean change from baseline (with 95% CIs of the change from baseline).

Analysis was undertaken at the wrist level for all outcomes of interest to the review, though all participants in each group had bilateral CTS. Bilateral cases had a different intervention applied to each wrist. The trialists did not report in the publication how the correlation between both wrists was accounted for in the analysis, and when contacted, confirmed that no such method was used. Therefore, a unit of analysis error is likely to have occurred. No attempt was made to adjust outcome data.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "A randomisation list was produced with a random number generator of a popular spreadsheet program (Lotus Symphony)".

Allocation concealment (selection bias)Low riskQuote: "An ultrasound therapist not involved in the treatment allocated the dominant wrist of each consecutive patient to ultrasound or sham treatment-by means of sequentially numbered sealed opaque envelopes containing the group allocation..."

Blinding of participants and personnel (performance bias)
Self-reported outcomes
Low riskQuote: "The patients, study physician, and the therapists who delivered the ultrasound treatment were all unaware of the treatment allocation".

Quote: "An on/off key introduced into the transducer circuit allowed mock insonation to be given to a sham group without affecting the normal ultrasonic output when the key was turned to the "on" position".

Quote: "Intensity of ultrasound treatment was below sensitivity threshold."

Comment: Outcomes including subjective symptom assessment, sensation, and overall symptom improvement were self-reported by participants who were blinded to group assignments.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "(The ultrasound therapist not involved in the treatment...) was the only person aware of treatment allocation during the trial".

Comment: Outcomes including grip strength, pinch strength and nerve conduction studies were probably measured and assessed by personnel blinded to group assignments.

Incomplete outcome data (attrition bias)
3 months or less
Unclear riskComment: Eleven participants were not included in the analysis of outcomes measured at two weeks and seven weeks because of non-compliance in keeping appointments (8) and excessive pain requiring additional therapeutic measures (3). It is unclear whether it was still possible to assess and include some or all of the outcome data for these individuals or whether they had been inappropriately excluded from the analysis. 

Incomplete outcome data (attrition bias)
After 3 months
Unclear riskComment: Four participants were not accounted for in outcomes assessed at six months follow-up. Reasons were not provided in order to determine whether these were genuine losses to follow-up or exclusions.

Selective reporting (reporting bias)High riskComment: Nerve conduction studies assessing median motor nerve conduction and sensory nerve action potentials were conducted but results were not reported. Change scores were reported for all continuous outcomes probably due to slight group imbalances at baseline that were noted by the authors (mean end point scores and standard deviations have since been obtained for some time points through personal communication with the authors). It was reported that three participants were off work however, work status was not stated as an outcome measure in the methods section.

Other biasLow riskComment: No other sources of bias identified.

Ekim 2008

MethodsRandomised, single-blind placebo-controlled trial

Blinded participants


ParticipantsTotal n = 28 (28 wrists) randomised
Intervention group n = 15 wrists randomised; 15 wrists completed
Control group n = 13 wrists randomised; 13 wrists completed

8 males; 20 females

Mean ± SD age*:
Intervention group 50.73 ± 10.5 yrs
Control group 46.23 ± 10.6 yrs

Median (interquartile range) duration of symptoms

Intervention group 2.5 (1.5, 3.75) years

Control group 2 (1.875, 3) years

Inclusion criteria:
1. Diagnosed with CTS, as based on at least one of the following: (i) abnormal sensory nerve conduction of the palm-wrist segment; or (ii) prolonged motor distal latency. The median motor distal latency over 3.9 msec or reduced sensory nerve conduction velocity of the palm-wrist segment below 35.2 m/sec was accepted as CTS

Exclusion criteria:

1) Diabetes mellitus, hypothyroiditis, acromegaly, rheumatoid arthritis, cervical radiculopathy or severe polyneuropathy and conditions that occur secondarily to causes such as wrist trauma,

2) Patients who had physical therapy or steroid injection for CTS within the last 3 months,

3) The presence of muscle atrophy, anaesthesia or ongoing (unhealed or intractable) pain,

4) The presence of reinnervation or fibrillation potentials on EMG,

5) Any medical problem that does not allow the patients to be treated by US.


InterventionsIntervention group: Active continuous ultrasound of 1.5 W/cm2 intensity and 3 MHz frequency for five minutes, five days a week for two weeks, plus neutral splint worn at night for two weeks.

Control group: Placebo ultrasound of 0.0 W/cm2 intensity for five minutes, five days a week for two weeks, plus neutral splint worn at night for two weeks.


OutcomesOutcomes assessed at baseline and at the end of two weeks treatment:

1. Pain using a 100 mm VAS

2. Symptoms using the Turkish-translated version of the Levine questionnaire (Levine 1993)

3. Function using the Turkish-translated version of the Levine questionnaire (Levine 1993)

4. Grip strength using a dynamometer, with the average of three measurements recorded

5. Tinel's test

6. Phalen's test

7. Nerve conduction: motor distal latency, motor nerve conduction velocity, sensory distal latency, palm-wrist conduction velocity


NotesArticle is published in Turkish, and was translated by a translator organised by the Neuromuscular Disease Review Group.

All participants had unilateral CTS. Therefore, a unit of analysis error resulting from the correlation between two wrists in bilateral CTS participants could not have occurred.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote (translated from Turkish to English): "28 patients with idiopathic CTS fulfilling the criteria for the study were randomly allocated to 2 groups."

Comment: No information on how the random sequence was generated was reported.

Allocation concealment (selection bias)Unclear riskQuote (translated from Turkish to English): "28 patients with idiopathic CTS fulfilling the criteria for the study were randomly allocated to 2 groups."

Comment: No information on how the random sequence was concealed from those responsible for recruitment was reported.

Blinding of participants and personnel (performance bias)
Self-reported outcomes
Low riskQuote (translated from Turkish to English): "This study was planned as a single-blinded, randomized and prospective study..."
Quote (translated from Turkish to English): "28 patients with idiopathic CTS fulfilling the criteria for the study were randomly allocated to 2 groups. Group 1 patients (n: 15) underwent active continuous US of 1,5 W/cm2 dose while the Group 2 patients had placebo US (0,0 W/cm2). The generator of US was the Enraf Nonius Sonoplus 434 with a frequency of 3 MHz and a head size of 0,5 cm2. Aquasonic gel was used for coupling. The same equipment was used for placebo application. The equipment was switched on however no US waves were applied to the treatment area."

Comment: Participants were probably blinded to the treatment they were receiving. However, personnel delivering the treatment were not blinded.

Blinding of outcome assessment (detection bias)
All outcomes
High riskQuote (translated from Turkish to English): "This study was planned as a single-blinded, randomized and prospective study..."
Quote (translated from Turkish to English): "28 patients with idiopathic CTS fulfilling the criteria for the study were randomly allocated to 2 groups. Group 1 patients (n: 15) underwent active continuous US of 1,5 W/cm2 dose while the Group 2 patients had placebo US (0,0 W/cm2). The generator of US was the Enraf Nonius Sonoplus 434 with a frequency of 3 MHz and a head size of 0,5 cm2. Aquasonic gel was used for coupling. The same equipment was used for placebo application. The equipment was switched on however no US waves were applied to the treatment area."

Quote (translated from Turkish to English): "The same person performed the treatments to the palmar carpal tunnel area in a circular pattern for 5 minutes every 5 days of 2 weeks for both groups...The same physician performed the clinical evaluations of all patients at onset and the end of the study"

Comment: The individual responsible for delivering the treatment was the same individual or assessed outcomes, and was not blind to treatment.

Incomplete outcome data (attrition bias)
3 months or less
Low riskQuote (translated from Turkish to English): "...patients were evaluated daily and there were no patients who discontinued the study."

Comment: No drop-outs or losses to follow-up were reported.

Selective reporting (reporting bias)Low riskComment: All outcomes reported in the Methods section of the publication were reported in the Results section of the publication. Outcomes were all reported as means and SDs, except for the outcome, VAS pain, which was reported as medians and interquartile ranges because the data were skewed.

Other biasLow riskComment: No other sources of bias identified.

Koyuncu 1995

MethodsRandomised, double-blind clinical trial

Blinded participants and outcome assessors

It is unclear whether randomisation occurred at the level of participants or wrists, and whether all bilateral CTS participants received the same or different intervention for each wrist


ParticipantsTotal n = 16 participants (21 wrists) randomised
Group 1 n = 10 wrists randomised
Group 2 n = 11 wrists randomised

1 male; 15 females

Median ± SD age: 49.4 ± 2.7 yrs

Inclusion criteria:
1. Clinical diagnosis of CTS based on physical findings and confirmed with electrodiagnostic testing (detail not specified)

Exclusion criteria:
None stated


InterventionsGroup 1: Circular ultrasound therapy over volar wrist surface using 1.0 W/cm2 intensity and 1MHz frequency, 8 minute session, 5 days per week, for 4 weeks (total of 20 sessions)

Group 2: Circular ultrasound therapy over volar wrist surface using 1.0 W/cm2 intensity and 3MHz frequency, 8 minute session, 5 days per week, for 4 weeks (total of 20 sessions)


OutcomesOutcome assessed weekly and at end of treatment (4 weeks)

1. Pain using ordinal scale 0-3 (0 = no pain, 1 = mild, 2 = moderate, 3 = severe)
2. Paraesthesiae using ordinal scale 0-3 (0 = none, 1 = mild, 2 = moderate, 3 = severe)
3. Superficial touch sensation using dichotomous scale (0 = normal, 1 = decreased)
4. Large object grasping using dichotomous scale (0 = normal, 1 = decreased)
5. Small object grasping using dichotomous scale (0 = normal, 1 = decreased)
6. Motor nerve distal transmission delay*
7. Sensory nerve transmission delay*
8. Tinel's sign
9. Phalen's sign


NotesArticle is published in Turkish, and was translated by a translator organised by the Neuromuscular Disease Review Group. Attempts to clarify allocation method with authors were unsuccessful

*Note. Only median values for neurophysiological endpoints were published by authors. Attempts to obtain mean and SD data were unsuccessful.

Analysis was undertaken at the wrist level for all outcomes, though some participants in each group had bilateral CTS. It is not clear whether bilateral CTS participants received the same intervention for both wrists. The trialists did not report how the correlation between both wrists was accounted for in the analysis, and attempts to clarify this information from the trialists were unsuccessful. Therefore, it is not clear whether a unit of analysis error occurred. No attempt was made to adjust outcome data.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "patients were randomly divided into two groups".

Comment: Insufficient information to determine whether the method used to generate the allocation sequence was adequate. 

Allocation concealment (selection bias)Unclear riskComment: Insufficient information to determine whether allocation was concealed. 

Blinding of participants and personnel (performance bias)
Self-reported outcomes
Low riskComment: The study is described as double-blinded however it does not specify who was blinded in the trial. It is likely that participants were blinded which would minimise bias in the assessment of self-reported outcomes including pain, paraesthesia, and superficial touch sensation.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskComment: The study is described as double blind, however the authors do not specify who was blinded (i.e. those delivering the intervention or those assessing outcomes).

Incomplete outcome data (attrition bias)
3 months or less
Low riskComment: There are no apparent losses to follow-up or exclusions in the results reported from this study.

Selective reporting (reporting bias)High riskComment: Outcomes were assessed every week throughout the 4 week treatment period however, only results for before and after treatment are reported.  Results for motor nerve distal transmission delay and sensory nerve transmission delay may have been selectively reported as only median values and mean change scores (without measures of variance) were reported. 

Other biasLow riskComment: No other sources of bias identified.

Oztas 1998

MethodsRandomised, single-blind, placebo-controlled trial

Blinded participants

Randomisation occurred at the level of wrists, with no constraint that all participants' wrist be allocated to the same or different treatments


ParticipantsTotal n = 18 (30 wrists) randomised
Intervention group 1 n = 7 (10 wrists) randomised
Intervention group 2 n = 9 (10 wrists) randomised
Control group n = 9 (10 wrists) randomised

0 males, 18 females

Mean ± SD age: 52 ± 7 yrs

Inclusion criteria:
1. Clinical diagnosis of CTS confirmed with electrodiagnostic studies
2. Symptom duration greater or equal to 6 months

Exclusion criteria:
1. Diabetes mellitus
2. Rheumatic disease
3. Acute trauma
4. Pregnancy
5. Physical or medical therapy in previous month
6. Corticosteroid injection in previous 3 months
7. Serious medical problems interfering with electrodiagnostic studies
8. Medical problems contraindicating use of ultrasound
9. Muscle atrophy, anaesthesia or intractable pain due to CTS


InterventionsIntervention group 1: Continuous ultrasound therapy using 1.5 W/cm2 intensity and 3 MHz frequency, 5 minute session, 5 days per week, for 2 weeks

Intervention group 2: Continuous ultrasound therapy using 0.8 W/cm2 intensity and 3 MHz frequency, 5 minute session, 5 days per week, for 2 weeks

Control: Placebo treatment using 0.0 W/cm2 intensity without energy emission, 5 minute session, 5 days per week, for 2 weeks


OutcomesOutcome assessed at 2 weeks 5 days

1. Pain severity (100mm horizontal VAS)
2. Symptoms* (nocturnal, day pain, paraesthesia on ordinal scale: 0 = no symptoms, 1 = mild, 2 = moderate, 3 = severe)
3. Nocturnal waking* (ordinal scale: 0 = never wake, 1 = awaken 1-2 times a week, 2 = awaken 3-6 times per week, 3 = awaken 7 times or more)
4. Nerve conduction: median motor and sensory distal latencies, median motor forearm conduction velocity, sensory nerve conduction velocity


NotesAttempts to clarify allocation method with authors were unsuccessful

*Note. These outcomes used short ordinal scales which should be treated as binary data. Authors reported as continuous data. Attempts to obtain raw data from authors were unsuccessful.

Analysis was undertaken at the wrist level for all outcomes, though some participants in each group had bilateral CTS. Some bilateral CTS participants received the same intervention for both wrists while others received different interventions for each wrist. The trialists did not report how the correlation between both wrists was accounted for in the analysis, and attempts to clarify this information from the trialists were unsuccessful. Therefore, it is not clear whether a unit of analysis error occurred. No attempt was made to adjust outcome data.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "Eighteen patients who were found to have a total of 30 idiopathic cases of CTS were randomly divided into three groups, each with 10 cases of CTS."

Comment: Not enough information to determine the adequacy of the randomisation sequence generation.

Allocation concealment (selection bias)Unclear riskQuote: "Eighteen patients who were found to have a total of 30 idiopathic cases of CTS were randomly divided into three groups, each with 10 cases of CTS."

Comment: Not enough information to determine whether the allocation sequence was adequately concealed until interventions were assigned.

Blinding of participants and personnel (performance bias)
Self-reported outcomes
Low riskQuote: "The ultrasound therapy lasted 5 minutes per session, 5 days a week for 2 weeks, and patients were unaware of treatment groups."

Comment: Participants were probably blind to treatment allocation.

Blinding of outcome assessment (detection bias)
All outcomes
High riskQuote: "Design: Patient-blinded, placebo-controlled, before-after treatment trial."

Comment: It is likely that outcome assessors were not blinded to treatment allocation as it can be assumed that is this were the case, this would be stated in the above quote.

Incomplete outcome data (attrition bias)
3 months or less
Unclear riskComment: No withdrawals or drop-outs were reported, but since the number of cases included in each analysis was not reported in any of the tables of results, it cannot be determined whether all outcomes were based on a complete dataset.

Selective reporting (reporting bias)Unclear riskComment: All outcomes specified in the Methods section of the publication were reported in the pre-specified way. However, unlike the majority of other included studies, this study did not measure the outcome, function or health-related quality of life. As no protocol for the study could be obtained, it is not clear whether this outcome was measured and subsequently not reported.

Other biasLow riskComment: No other sources of bias identified.

Piravej 2004

MethodsRandomised double-blind clinical trial

Blinded participants and outcome assessors

Randomisation occurred at the level of participants, not wrists (i.e. participants with bilateral CTS received the same intervention for both wrists)


ParticipantsTotal n = 18 (30 wrists) randomised and completed
Intervention group 1 n = 10 (15 wrists) randomised and completed
Intervention group 2 n = 8 (15 wrists) randomised and completed

0 males and 18 females

Mean ± SD age

Intervention group 1: 49.07 ± 8.88 yrs

Intervention group 2: 44.87 ± 7.55 yrs

Inclusion criteria:
1. Clinical manifestation of CTS of less than 12 months
2. Musculoskeletal problems or specific predisposing factors, such as rheumatic diseases, diabetes mellitus, cervical spondylosis, acute trauma and pregnancy
3. No treatment for at least one month
4. No local corticosteroid injection during the last three months
5. No serious co-existing medical condition that may prohibit electrophysiological test during the study
6. No allergy or contraindication for diclofenac and ultrasound therapy
7. No muscle atrophy, anaesthesia or intractable pain due to CTS

8. Electrophysiologic test showed the presence of median nerve sensory and motor responses with sensory distal latency longer than 2.8 msec but not more than 4.50 msec, sensory nerve action potential (SNAP) amplitude exceeding 10 uv, median-ulnar mixed nerve latency difference longer than 0.5 msec, motor distal latency (MDL) longer than 4.2 msec but not more than 6.50 msec and compound muscle action potential (CMAP) amplitude not less than 5.0 mV

9. Electromyography of the abductor pollicis brevis (APB) muscle showed no spontaneous activity or markedly reduced firing frequency

10. The patient accepted the study and signed the consent form

Exclusion criteria:

Not reported (implied by inclusion criteria)


InterventionsIntervention group 1: Continuous ultrasound therapy in a circular fashion performed at intensity of 0.5 W/cm2 and frequency of 1 MHz for 10 minutes per session, 5 days a week for 4 weeks, plus placebo drug taken each day.

Intervention group 2: "Sham" ultrasound therapy in a circular fashion performed at intensity of 0.0 W/cm2 and frequency of 1 MHz for 10 minutes per session, 5 days a week for 4 weeks, plus diclofenac 75 mg/day (a nonsteroidal anti-inflammatory drug) taken in a divided dose each day.


OutcomesOutcomes assessed at baseline and within five days after the end of four weeks treatment

1. Pain using zero to 100 VAS (0 = "no pain", 10 = "unbearable pain")
2. Presence of pain and/or paraesthesia symptoms at night and/or day, scored as follows: 0 = no symptoms, 1 = mild (nocturnal and/or diurnal paraesthesia ), 2 = moderate (nocturnal pain and paraesthesia ), and 3 = severe (nocturnal and diurnal pain and paraesthesia)
3. Frequency of awakening of symptoms at night per week scored as follows: 0 = never wake up; 1 = 1-2 times a week; 2 = 3-6 times a week; and 3 = 7 times or more
4. Nerve conduction: median nerve sensory distal latency, sensory nerve action potential amplitude (SNAP), median nerve motor distal latency* and compound muscle action potential (CMAP)


NotesThe authors reported the mean and SD for all outcomes as endpoint scores and change from baseline scores, however, the SD of the median nerve motor distal latency endpoint score appears to have been reported incorrectly in the study (SD before treatment is 0.67 whereas for after treatment it is reported as 25.67). Therefore, only the change from baseline scores for the outcome, median nerve motor distal latency, was entered into RevMan. Attempts to contact the authors for clarification of this were unsuccessful.

Analysis was undertaken at the wrist level for all outcomes, though some participants in each group had bilateral CTS. Bilateral cases had the same intervention applied to each wrist. The trialists did not report how the correlation between both wrists was accounted for in the analysis, and attempts to clarify this information from the trialists were unsuccessful. Therefore, it is not clear whether a unit of analysis error occurred. No attempt was made to adjust outcome data.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "A physician simple randomized the patients into 2 groups by drawing a paper which was labelled A or B of 15 cases without replacement."

Comment: Randomisation sequence was probably adequately concealed.

Allocation concealment (selection bias)Unclear riskQuote: "A physician simple randomized the patients into 2 groups by drawing a paper which was labelled A or B of 15 cases without replacement."

Comment: Not clear whether the allocation sequence was adequately concealed.

Blinding of participants and personnel (performance bias)
Self-reported outcomes
Low riskQuote: "...patients were unaware of the treatment groups."

Comment: Blinding of participants was probably achieved, given that placebo drug and sham ultrasound were used.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "The electrophysiological tests were performed by the same physician, who did not involve with treatment assignment."

Comment: Outcome assessor was probably blind to treatment allocation.

Incomplete outcome data (attrition bias)
3 months or less
Low riskComment: No drop-outs were reported.

Selective reporting (reporting bias)Unclear riskComment: All outcomes reported in the Methods section of the publication were reported fully in the Results section. However, unlike the majority of other included studies, this study did not measure the outcome, function or health-related quality of life. As no protocol for the study could be obtained, it is not clear whether this outcome was measured and subsequently not reported.

Other biasLow riskComment: No other sources of bias identified.

Yildiz 2011

MethodsRandomised double-blind clinical trial

Blinded participants and outcome assessors

Randomisation occurred at the level of wrists, with no constraint that all participants' wrists be allocated to the same or different treatments


ParticipantsTotal n = 51 (76 wrists) randomised; 44 (68 wrists) completed
Intervention group 1 n = 17 (25 wrists) randomised; 16 (23 wrists) completed
Intervention group 2 n = 17 (26 wrists) randomised; 13 (22 wrists) completed
Intervention group 3 n = 17 (26 wrists) randomised; 15 (23 wrists) completed

8 males and 43 females randomised; 8 males; 36 females completed

Mean ± SD age

Intervention group 1 (randomised): 47.47 ± 8.07 yrs

Intervention group 1 (completed): 47.5 ± 8.33 yrs

Intervention group 2 (randomised): 48.41 ± 9.51 yrs

Intervention group 2 (completed): 48.76 ± 10.94 yrs

Intervention group 3 (randomised): 50.17 ± 10.47 yrs

Intervention group 3 (completed): 50.26 ± 11.19 yrs

Inclusion criteria:
1. Diagnosis of mild and moderate CTS according to American Association of Electrodiagnostic Medicine Guidelines
2. Symptom duration greater than one month

Exclusion criteria:
1. Corticosteroid injection before the study
2. Physical or medical therapy in the previous three months
3. Muscle atrophy due to CTS
4. Evidence of obvious underlying causes of CTS such as hypothyroidism, diabetes mellitus, inflammatory rheumatic diseases, arthritis of wrist, acute trauma, pregnancy
5. Medical problems that would have been contraindicated for ultrasound therapy
6. Clinical or electrophysiologic evidence of accompanying conditions that could mimic CTS or interfere with its evaluation such as cervical radiculopathy, or significant polyneuropathy
7. Presence of either fibrillation potentials or reinnervation on needle electromyography in the abductor pollicis brevis muscle


InterventionsIntervention group 1: Neutral (0° to 5°) custom-moulded thermoplastic volar wrist splint worn at night and during the day for eight weeks plus sham ultrasound (delivered with an acoustic gel without any medication via a Chattonooga Group, Model 27335 ultrasound system in off-mode) for 15 minutes sessions, once a day, five times a week for two weeks

Intervention group 2: Neutral (0° to 5°) custom-moulded thermoplastic volar wrist splint worn at night and during the day for eight weeks plus pulsed mode (1:4) ultrasound with an acoustic gel without any medication at 1 MHz frequency and 1 W/cm2 intensity for 15 minute sessions, once a day, five times a week for two weeks.

Intervention group 3: Neutral (0° to 5°) custom-moulded thermoplastic volar wrist splint worn at night and during the day for eight weeks plus pulsed mode (1:4) ultrasound with 2.5% ketoprofen gel (a nonsteroidal anti-inflammatory drug) at 1 MHz frequency and 1 W/cm2 intensity for 15 minute sessions, once a day, five times a week for two weeks.


OutcomesOutcomes assessed at baseline, at the end of two week treatment and six weeks after treatment ended*

1. Pain using zero to 10 VAS (0 = "no pain", 10 = "worst possible pain")
2. Symptoms using Boston carpal tunnel questionnaire (rates 11 items on ordinal scale 1: mildest, to 5: most severe) (Levine 1993)
3. Function using Boston carpal tunnel questionnaire (rates 8 items on ordinal scale 1: no difficulty with the activity, to 5: can not perform the activity at all) (Levine 1993)
4. Complications or side effects (not defined)
5. Nerve conduction: median nerve motor distal latency, median nerve sensory distal latency


Notes*Both an intention-to-treat and per-protocol analysis was conducted for all outcomes.

Analysis was undertaken at the wrist level for all outcomes, though some participants in each group had bilateral CTS. Some bilateral CTS participants received the same intervention for both wrists while others received different interventions for each wrist. The trialists did not report how the correlation between both wrists was accounted for in the analysis, and attempts to clarify this information from the trialists were unsuccessful. Therefore, it is not clear whether a unit of analysis error occurred. No attempt was made to adjust outcome data.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "A randomisation list was produced with a random number generator"

Comment: Randomisation sequence was likely adequately generated

Allocation concealment (selection bias)Unclear riskQuote: "After eligible patients had been enrolled, a physiatrist (GOG) who was not involved in the treatment allocated the involved wrist of each consecutive patient to PH, US or sham treatment group (same procedure was repeated for other involved wrist in patients with bilateral CTS) by means of sequentially numbered sealed envelopes containing the group allocation (sham, US or PH). This physiatrist was the only person aware of treatment allocation during the trial."

Comment: It is not clear whether the sequentially numbered sealed envelopes were opaque, therefore it is not clear whether the allocation sequence was adequately concealed until interventions were assigned.

Blinding of participants and personnel (performance bias)
Self-reported outcomes
Low riskQuote: "In addition to patients, NY, NSA and ES who delivered the treatment were all unaware of the treatment allocation. Only the physician (GOG) who was in charge of group allocation switched the ultrasonic generator to the respective modes before each treatment session. Both ketoprofen and acoustic gel tubes were covered. Sessions were arranged on a non-overlapping timetable so that different groups of patients were not able to see each other. This procedure allowed blinding of both the patients and the physicians delivering the treatment. Intensity of US treatment was below sensitivity threshold."

Comment: Patients were likely blinded to treatment allocation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "In addition to patients, NY, NSA and ES who delivered the treatment were all unaware of the treatment allocation. Only the physician (GOG) who was in charge of group allocation switched the ultrasonic generator to the respective modes before each treatment session. Both ketoprofen and acoustic gel tubes were covered. Sessions were arranged on a non-overlapping timetable so that different groups of patients were not able to see each other. This procedure allowed blinding of both the patients and the physicians delivering the treatment. Intensity of US treatment was below sensitivity threshold."

Quote: "Pre- and post-treatment (2nd and 8th week) evaluations of the patients were made with the following clinical outcome parameters by a physiatrist (NY) and electrophysiological outcome parameters by the other physiatrist (NSA)".

Comment: Outcome assessors were reported to be blinded to treatment allocation.

Incomplete outcome data (attrition bias)
3 months or less
Low riskQuote: "After completing two weeks of treatment, seven out of 51 randomised patients did not finish the study protocol (one in Group 1, four in Group 2 and two in Group 3) due to non-compliance to splinting, illness and lost to follow-up."

Quote: "The ITT analysis included all randomised patients who received treatment at least once"

Comment: The number of drop-outs in each group, and the reasons why, was clearly reported in text and in a Figure. The number of drop-outs was small and relatively similar across groups, suggesting low risk of bias.

Selective reporting (reporting bias)Low riskComment: All outcome measures described in the methods of the published article were reported in the results although a protocol was not available to determine whether all intended outcomes were included in the publication. Standard outcome measures have been reported and selective outcome reporting is unlikely. Data for all outcomes were reported separately based on an intention-to-treat and per-protocol analysis

Other biasLow riskComment: No other sources of bias identified.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Avci 2004Compares the effect of ultrasound plus paraffin bath versus other interventions for CTS (so we cannot determine the effect of ultrasound in isolation).

Bakhtiary 2011Investigates the effect of phonophoresis, which is the use of therapeutic ultrasound to enhance delivery of topically applied drugs, and so differs to the types of therapeutic ultrasound addressed in this review.

Coskun 2011Therapeutic ultrasound was provided to both groups (along with other non-surgical interventions for CTS).

Dakowicz 2005Not a randomised controlled trial; all patients received ultrasound therapy

Davis 1998Compares the effect of therapeutic ultrasound delivered as one component of a chiropractic intervention which also comprised manual thrusts, massage, and wrist splints, compared with ibuprofen and wrist splint (so we cannot determine the effect of ultrasound in isolation).

Deliss 1998Not a randomised controlled trial. This is a clinical commentary on the Ebenbichler 1998 trial.

Gurcay 2012Investigates the effect of phonophoresis, which is the use of therapeutic ultrasound to enhance delivery of topically applied drugs, and so differs to the types of therapeutic ultrasound addressed in this review.

Hui 2004Long-term follow-up of patients in Wong 2011 RCT, where efficacy of steroid injection is compared with oral steroids. Awaiting assessment in Marshall 2007 Cochrane review.

Jarvik 2009RCT comparing ultrasound with other non-surgical interventions to a surgical intervention for CTS; RCTs comparing surgical to non-surgical interventions for CTS are the focus of another Cochrane review (Verdugo 2008)

Lucas 2002Not a randomised controlled trial. This is a critical appraisal of the Ebenbichler 1998 RCT.

Robertson 2001Review of therapeutic ultrasound for treating pain, musculoskeletal injuries and soft tissue lesions.

Sucher 1999Not a randomised clinical trial. This is a clinical commentary on the Oztas 1998 trial.

Taspinar 2007Compares the effect of ultrasound plus transcutaneous electrical nerve stimulation (TENS) versus other interventions for CTS (so we cannot determine the effect of ultrasound in isolation)

Toro 1997Therapeutic ultrasound was provided to both groups (along with other non-surgical interventions for CTS).

Walling 1998Not a randomised controlled trial. This is a brief summary of the Ebenbichler 1998 RCT.

 
Characteristics of ongoing studies [ordered by study ID]
NCT01590745

Trial name or titleUltrasound therapy for carpal tunnel syndrome (CTS)

Methods

Participants

Interventions

Outcomes

Starting date

Contact information

NotesClinicalTrials.gov ID NCT01590745 (http://clinicaltrials.gov/show/NCT01590745).

 
Comparison 1. Therapeutic ultrasound versus placebo

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

 1 Short-term overall improvement (number of participants with good to excellent improvement) (3 months or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 At 7 weeks (end of treatment)
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Short-term improvement in CTS symptoms (number of participants with complete remission of subjective symptoms) (3 months or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 At 7 weeks (end of treatment)
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Short-term improvement in CTS symptoms (VAS pain score) (2 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 After 2 weeks of treatment (1.5 W/cm2 intensity) (endpoint values)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 After 2 weeks of treatment (0.8 W/cm2 intensity) (endpoint values)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Short-term improvement in CTS symptoms (pain and/or paraesthesia) (3 months or less)2Mean Difference (IV, Random, 95% CI)Totals not selected

    4.1 After 2 weeks of treatment (endpoint values of Ebenbichler 1998)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

    4.2 After 2 weeks of treatment (endpoint values of Oztas 1998 1.5 W/cm2 intensity)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

    4.3 After 2 weeks of treatment (endpoint values of Oztas 1998 0.8 W/cm2 intensity)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

    4.4 After 7 weeks of treatment (endpoint values in Ebenbichler 1998)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 5 Short-term improvement in CTS symptoms (sensory loss) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    5.1 Change from baseline to two weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    5.2 Change from baseline to seven weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 Short-term improvement in CTS symptoms (nocturnal waking) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    6.1 After 2 weeks of treatment (1.5 W/cm2 intensity) (endpoint values)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    6.2 After 2 weeks of treatment (0.8 W/cm2 intensity) (endpoint values)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 7 Short-term improvement in functional ability (hand grip strength) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    7.1 Change from baseline to two weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    7.2 Change from baseline to seven weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 8 Short-term improvement in functional ability (pinch strength) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    8.1 Change from baseline to two weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    8.2 Change from baseline to seven weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 9 Short-term improvement in motor distal latency (ms) (3 months or less)2Mean Difference (IV, Random, 95% CI)Totals not selected

    9.1 After 2 weeks treatment (change from baseline values in Ebenbichler 1998)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

    9.2 After 2 weeks treatment (endpoint values in Oztas 1998 1.5 W/cm2 intensity)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

    9.3 After 2 weeks treatment (endpoint values in Oztas 1998 0.8 W/cm2 intensity)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

    9.4 Change from baseline to 7 weeks in Ebenbichler 1998
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 10 Short-term improvement in motor nerve conduction velocity (m/s) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    10.1 After 2 weeks 5 days treatment (1.5 W/cm2 intensity) (endpoint values)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    10.2 After 2 weeks 5 days treatment (0.8 W/cm2 intensity) (endpoint values)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 11 Short-term improvement in sensory distal latency (ms) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    11.1 After 2 weeks 5 days treatment (1.5 W/cm2 intensity) (endpoint values)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    11.2 After 2 weeks 5 days treatment (0.8 W/cm2 intensity) (endpoint values)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 12 Short-term improvement in sensory nerve conduction velocity (3 months or less)2Mean Difference (IV, Random, 95% CI)Totals not selected

    12.1 After 2 weeks treatment (change from baseline values in Ebenbichler 1998)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

    12.2 After 2 weeks treatment (endpoint values in Oztas 1998 1.5 W/cm2 intensity)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

    12.3 After 2 weeks treatment (endpoint values in Oztas 1998 0.8 W/cm2 intensity)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

    12.4 Change from baseline to 7 weeks
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 13 Long-term improvement in CTS symptoms (>3 months) (number of participants who did not have an overall unsatisfactory outcome)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    13.1 At 7 months and 3 weeks (endpoint values)
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 14 Long-term improvement in CTS symptoms (number of participants with complete remission of subjective symptoms) (>3 months)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    14.1 At 7 months and 3 weeks (endpoint values)
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 15 Long-term improvement in CTS symptoms (pain and/or paraesthesia) (>3 months)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    15.1 At 7 months 3 weeks (endpoint values)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 16 Long-term improvement in CTS symptoms (sensory loss) (>3 months)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    16.1 At 7 months 3 weeks (endpoint values)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 17 Long-term improvement in functional ability (grip and pinch strength) (>3 months)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    17.1 Grip strength (kg) at 7 months and 3 weeks (endpoint values)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    17.2 Pinch strength (kg) at 7 months and 3 weeks (endpoint values)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 2. Therapeutic ultrasound (varying frequency)

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

 1 Short-term improvement in CTS symptoms (pain) (3 months or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 After 4 weeks of treatment
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Short-term improvement in CTS symptoms (paraesthesia) (3 months or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 After 4 weeks of treatment
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Short-term improvement in CTS symptoms (superficial sensation) (3 months or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    3.1 After 4 weeks of treatment
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Short-term improvement in CTS symptoms (Tinel's sign) (3 months or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    4.1 After 4 weeks of treatment
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Short-term improvement in CTS symptoms (Phalen's sign) (3 months or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    5.1 After 4 weeks of treatment
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 Short-term improvement in functional ability (3 months or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    6.1 Grasp of large objects after 4 weeks of treatment
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    6.2 Grasp of small objects after 4 weeks of treatment
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 3. Therapeutic ultrasound (single intervention) versus low-level laser therapy

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

 1 Short-term improvement in CTS symptoms (VAS pain) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 Change from baseline to end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 Change from baseline to 7 weeks follow-up
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Short-term improvement in functional ability (hand grip strength, N) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    2.1 Change from baseline to end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.2 Change from baseline to 7 weeks follow-up
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Short-term improvement in functional ability (pinch strength, N) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 Change from baseline to end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 Change from baseline to 7 weeks follow-up
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Short-term improvement in motor distal latency (ms) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    4.1 Change from baseline to end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.2 Change from baseline to 7 weeks follow-up
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Short-term improvement in compound muscle action potential (CMAP) amplitude (mV) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    5.1 Change from baseline to end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    5.2 Change from baseline to 7 weeks follow-up
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 Short-term improvement in thumb sensory latency (ms) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    6.1 Change from baseline to end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    6.2 Change from baseline to 7 weeks follow-up
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 7 Short-term improvement in thumb sensory action potential (SAP) amplitude (µV) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    7.1 Change from baseline to end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    7.2 Change from baseline to 7 weeks follow-up
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 8 Short-term improvement in index sensory latency (ms) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    8.1 Change from baseline to end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    8.2 Change from baseline to 7 weeks follow-up
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 9 Short-term improvement in index sensory action potential (SAP) amplitude (µV) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    9.1 Change from baseline to end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    9.2 Change from baseline to 7 weeks follow-up
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 4. Therapeutic ultrasound (varying intensity)

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

 1 Short-term improvement in CTS symptoms (VAS pain) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 After 2 weeks 5 days of treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Short-term improvement in CTS symptoms (night pain / paraesthesia) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    2.1 After 2 weeks 5 days of treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Short-term improvement in CTS symptoms (nocturnal awakening) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 After 2 weeks 5 days of treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Short-term improvement in motor distal latency (ms) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    4.1 After 2 weeks 5 days treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Short-term improvement in motor nerve conduction velocity (m/s) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    5.1 After 2 weeks 5 days treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 Short-term improvement in sensory distal latency (ms) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    6.1 After 2 weeks 5 days treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 7 Short-term improvement in sensory nerve conduction velocity (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    7.1 After 2 weeks 5 days treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 5. Therapeutic ultrasound (single intervention) versus local corticosteroid injection plus splint

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

 1 Short-term improvement in CTS symptoms (symptom severity score) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 At the end of 4 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 4 weeks post-treatment cessation
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Short-term improvement in CTS symptoms (VAS pain) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    2.1 At the end of 4 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.2 4 weeks post-treatment cessation
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Short-term improvement in functional ability (functional status score) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 At the end of 4 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 4 weeks post-treatment cessation
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Short-term improvement in functional ability (grip strength) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    4.1 At the end of 4 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.2 4 weeks post-treatment cessation
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Short-term improvement in median nerve motor distal latency (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    5.1 At the end of 4 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    5.2 4 weeks post-treatment cessation
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 Short-term improvement in median sensory nerve conduction velocity (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    6.1 At the end of 4 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    6.2 4 weeks post-treatment cessation
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 6. Therapeutic ultrasound plus splint versus exercises plus splint

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

 1 Short-term improvement in CTS symptoms (VAS pain) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 After end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 At 11 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Short-term improvement in CTS symptoms (Levine) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    2.1 After end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.2 At 11 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Short-term improvement in CTS symptoms (Phalen sign) (3 months or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    3.1 At end of treatment (3 weeks)
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 At 11 weeks
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Short-term improvement in CTS symptoms (Tinel sign) (3 months or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    4.1 At end of treatment (3 weeks)
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.2 At 11 weeks
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Short-term improvement in functional ability (Levine) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    5.1 After end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    5.2 At 11 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 Short-term improvement in functional ability (hand grip strength) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    6.1 After end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    6.2 At 11 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 7 Short-term improvement in functional ability (pinch strength) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    7.1 After end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    7.2 At 11 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 8 Short-term improvement in motor distal latency (ms) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    8.1 After end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    8.2 At 11 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 9 Short-term improvement in sensory distal latency (ms) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    9.1 After end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    9.2 At 11 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 10 Long-term improvement in CTS symptoms (>3 months)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    10.1 At 11 months
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 7. Therapeutic ultrasound plus exercises plus splint versus exercises plus splint

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

 1 Short-term improvement in CTS symptoms (VAS pain) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 After end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 At 11 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Short-term improvement in CTS symptoms (Levine) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    2.1 After end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.2 At 11 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Short-term improvement in CTS symptoms (Phalen sign) (3 months or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    3.1 At end of treatment (3 weeks)
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 At 11 weeks
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Short-term improvement in CTS symptoms (Tinel sign) (3 months or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    4.1 At end of treatment (3 weeks)
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.2 At 11 weeks
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Short-term improvement in functional ability (Levine) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    5.1 After end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    5.2 At 11 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 Short-term improvement in functional ability (hand grip strength) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    6.1 After end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    6.2 At 11 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 7 Short-term improvement in functional ability (pinch strength) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    7.1 After end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    7.2 At 11 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 8 Short-term improvement in motor distal latency (ms) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    8.1 After end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    8.2 At 11 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 9 Short-term improvement in sensory distal latency (ms) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    9.1 After end of 3 weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    9.2 At 11 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 10 Long-term improvement in CTS symptom (>3 months)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    10.1 At 11 months
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 8. Therapeutic ultrasound plus splint versus splint

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

 1 Short-term overall improvement (completely normal hands based on electroneuromyography) (3 months or less)1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

 2 Short-term overall improvement (patient satisfaction) (3 months or less)1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

 3 Short-term improvement in CTS symptoms (symptom severity score) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 At 1 month after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 At 3 months after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Short-term improvement in CTS symptoms (VAS pain) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    4.1 At 1 month after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.2 At 3 months after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Short-term improvement in functional ability (functional status score) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    5.1 At 1 month after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    5.2 At 3 months after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 Short-term improvement in median nerve motor distal latency (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    6.1 At 1 month after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    6.2 At 3 months after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 7 Short-term improvement in second digit-wrist median nerve sensory velocity (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    7.1 At 1 month after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    7.2 At 3 months after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 9. Therapeutic ultrasound plus splint versus low-level laser therapy plus splint

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

 1 Short-term overall improvement (completely normal hands based on electroneuromyography) (3 months or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Short-term overall improvement (patient satisfaction) (3 months or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 Short-term improvement in CTS symptoms (symptom severity score) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 At 1 month after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 At 3 months after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Short-term improvement in CTS symptoms (VAS pain) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    4.1 At 1 month after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.2 At 3 months after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Short-term improvement in functional ability (functional status score) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    5.1 At 1 month after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    5.2 At 3 months after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 Short-term improvement in median nerve motor distal latency (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    6.1 At 1 month after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    6.2 At 3 months after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 7 Short-term improvement in second digit-wrist median nerve sensory velocity (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    7.1 At 1 month after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    7.2 At 3 months after treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 10. Therapeutic ultrasound plus nerve and tendon gliding exercises plus night splint plus activity modification versus dexamethasone iontophoresis plus nerve and tendon gliding exercises plus night splint plus activity modification

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

 1 Short-term improvement in CTS symptoms (BCTQ symptom severity score) (3 months or less)1Mean Difference (IV, Random, 95% CI)Totals not selected

    1.1 End of treatment (endpoint values)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

    1.2 Three months post-treatment cessation (endpoint values)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 2 Short-term improvement in CTS symptoms (VAS pain on movement) (3 months or less)1Mean Difference (IV, Random, 95% CI)Totals not selected

    2.1 Change from baseline to end of treatment
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 3 Short-term improvement in CTS symptoms (VAS pain at rest) (3 months or less)1Mean Difference (IV, Random, 95% CI)Totals not selected

    3.1 Change from baseline to end of treatment
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 4 Short-term improvement in CTS symptoms (VAS pain at night) (3 months or less)1Mean Difference (IV, Random, 95% CI)Totals not selected

    4.1 Change from baseline to end of treatment
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 5 Short-term improvement in functional ability (BCTQ functional status score) (3 months or less)1Mean Difference (IV, Random, 95% CI)Totals not selected

    5.1 End of treatment (endpoint values)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

    5.2 Three months post-treatment cessation (endpoint values)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 6 Short-term improvement in functional ability (Health Assessment Questionnaire) (3 months or less)1Mean Difference (IV, Random, 95% CI)Totals not selected

    6.1 End of treatment (endpoint values)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

    6.2 Three months post-treatment cessation (endpoint values)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 
Comparison 11. Therapeutic ultrasound plus nerve and tendon gliding exercise plus night splint plus activity modification versus placebo iontophoresis plus nerve and tendon gliding exercises plus night splint plus activity modification

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

 1 Short-term improvement in CTS symptoms (BCTQ symptom severity score) (3 months or less)1Mean Difference (IV, Random, 95% CI)Totals not selected

    1.1 End of treatment (endpoint values)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

    1.2 Three months post-treatment cessation (endpoint values)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 2 Short-term improvement in CTS symptoms (VAS pain on movement) (3 months or less)1Mean Difference (IV, Random, 95% CI)Totals not selected

    2.1 Change from baseline to end of treatment
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 3 Short-term improvement in CTS symptoms (VAS pain at rest) (3 months or less)1Mean Difference (IV, Random, 95% CI)Totals not selected

    3.1 Change from baseline to end of treatment
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 4 Short-term improvement in CTS symptoms (VAS pain at night) (3 months or less)1Mean Difference (IV, Random, 95% CI)Totals not selected

    4.1 Change from baseline to end of treatment
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 5 Short-term improvement in functional ability (BCTQ functional status score) (3 months or less)1Mean Difference (IV, Random, 95% CI)Totals not selected

    5.1 End of treatment (endpoint values)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

    5.2 Three months post-treatment cessation (endpoint values)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 6 Short-term improvement in functional ability (Health Assessment Questionnaire) (3 months or less)1Mean Difference (IV, Random, 95% CI)Totals not selected

    6.1 End of treatment (endpoint values)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

    6.2 Three months post-treatment cessation (endpoint values)
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 
Comparison 12. Therapeutic ultrasound plus splint versus placebo ultrasound plus splint

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

 1 Short-term improvement in CTS symptoms (Tinel's sign) (3 months or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 At the end of two weeks treatment
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Short-term improvement in CTS symptoms (Phalen's sign) (3 months or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 At the end of two weeks treatment
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Short-term improvement in CTS symptoms (symptom severity score) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 At the end of two weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Short-term improvement in functional ability (functional status score) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    4.1 At the end of two weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Short-term improvement in functional ability (grip strength) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    5.1 At the end of two weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 Short-term improvement in motor distal latency (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    6.1 At the end of two weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 7 Short-term improvement in motor nerve conduction velocity (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    7.1 At the end of two weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 8 Short-term improvement in sensory distal latency (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    8.1 At the end of two weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 9 Short-term improvement in palm-wrist conduction velocity (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    9.1 At the end of two weeks treatment
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 13. Therapeutic ultrasound plus placebo versus sham ultrasound plus NSAID

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

 1 Short-term improvement in CTS symptoms (pain and/or paraesthesia) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 Endpoint scores
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 Change from baseline scores
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Short-term improvement in CTS symptoms (frequency of awakening) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    2.1 Endpoint scores
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.2 Change from baseline scores
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Short-term improvement in median nerve sensory distal latency (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 Endpoint scores
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 Change from baseline scores
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Short-term improvement in sensory nerve action potential (SNAP) (endpoint) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    4.1 Endpoint scores
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Short-term improvement in sensory nerve action potential (SNAP) (change from baseline) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    5.1 Change from baseline scores
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 Short-term improvement in median nerve motor distal latency (change from baseline) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    6.1 Change from baseline scores
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 7 Short-term improvement in compound muscle action potential (CMAP) (endpoint) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    7.1 Endpoint scores
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 8 Short-term improvement in compound muscle action potential (CMAP) (change from baseline) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    8.1 Change from baseline scores
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 9 Short-term improvement in CTS symptoms (VAS pain) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    9.1 Endpoint scores
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    9.2 Change from baseline scores
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 14. Therapeutic ultrasound plus splint versus sham ultrasound plus splint

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

 1 Adverse events1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    1.1 ITT analysis
151Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 Per protocol analysis
145Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Short-term improvement in CTS symptoms (VAS pain) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    2.1 At end of 2 weeks treatment (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.2 At end of two weeks treatment (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.3 6 weeks after treatment ended (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.4 6 weeks after treatment ended (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Short-term improvement in CTS symptoms (symptom severity score) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 At end of 2 weeks treatment (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 At end of two weeks treatment (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.3 6 weeks after treatment ended (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.4 6 weeks after treatment ended (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Short-term improvement in functional ability (functional status score) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    4.1 At end of 2 weeks treatment (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.2 At end of two weeks treatment (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.3 6 weeks after treatment ended (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.4 6 weeks after treatment ended (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Short-term improvement in median nerve motor distal latency (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    5.1 At end of 2 weeks treatment (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    5.2 At end of two weeks treatment (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    5.3 6 weeks after treatment ended (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    5.4 6 weeks after treatment ended (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 Short-term improvement in median nerve sensory distal latency (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    6.1 At end of 2 weeks treatment (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    6.2 At end of two weeks treatment (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    6.3 6 weeks after treatment ended (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    6.4 6 weeks after treatment ended (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 15. Therapeutic ultrasound plus splint versus therapeutic ultrasound plus splint plus ketoprofen phonophoresis

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

 1 Adverse events1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    1.1 ITT analysis
151Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 Per protocol analysis
145Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Short-term improvement in CTS symptoms (VAS pain) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    2.1 At end of 2 weeks treatment (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.2 At end of 2 weeks treatment (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.3 6 weeks after treatment ended (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.4 6 weeks after treatment ended (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Short-term improvement in CTS symptoms (symptom severity score) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 At end of 2 weeks treatment (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 At end of 2 weeks treatment (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.3 6 weeks after treatment ended (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.4 6 weeks after treatment ended (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Short-term improvement in functional ability (functional status score) (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    4.1 At end of 2 weeks treatment (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.2 At end of 2 weeks treatment (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.3 6 weeks after treatment ended (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.4 6 weeks after treatment ended (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Short-term improvement in median nerve motor distal latency (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    5.1 At end of 2 weeks treatment (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    5.2 At end of 2 weeks treatment (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    5.3 6 weeks after treatment ended (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    5.4 6 weeks after treatment ended (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 Short-term improvement in median nerve sensory distal latency (3 months or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    6.1 At end of 2 weeks treatment (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    6.2 At end of 2 weeks treatment (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    6.3 6 weeks after treatment ended (ITT analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    6.4 6 weeks after treatment ended (per protocol analysis)
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Summary of findings for the main comparison. Therapeutic ultrasound compared with placebo for carpal tunnel syndrome (CTS)

Therapeutic ultrasound compared with placebo for carpal tunnel syndrome

Patient or population: patients with CTS
Settings: outpatient clinic of university department of physical medicine and rehabilitation, Vienna, Austria
Intervention: therapeutic ultrasound
Comparison: placebo

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

PlaceboTherapeutic ultrasound

Short-term overall improvement (three months or less)Study populationRR 2.36
(1.4 to 3.98)
68
(1 study)
⊕⊕⊝⊝
low2,3

324 per 10001765 per 1000
(454 to 1000)

Adverse effectsSee commentSee commentNot estimable68
(1 study)
⊕⊕⊝⊝
low2,3
No adverse effects were reported in the intervention or control groups

Short-term improvement in pain and/or paraesthesia (after seven weeks of treatment)

Scale from: zero to 10
The mean improvement in pain and/or paraesthesia (after seven weeks of treatment) in the control groups was
2.68
The mean improvement in pain and/or paraesthesia (after seven weeks of treatment) in the intervention groups was
0.99 lower
(1.77 to 0.21 lower)
68
(1 study)
⊕⊕⊝⊝
low2,3

Short-term improvement in hand grip strength (change from baseline to seven weeks)The mean improvement in hand grip strength (change from baseline to seven weeks) in the control groups was
-0.09 kilograms
The mean improvement in hand grip strength (change from baseline to seven weeks) in the intervention groups was
3.96 higher
(1.31 to 6.61 higher)
90
(1 study)
⊕⊕⊝⊝
low2,3

Long-term improvement in CTS symptoms (number of participants with complete remission of subjective symptoms) (six months follow-up)Study populationRR 3.67
(1.74 to 7.74)
60
(1 study)
⊕⊕⊝⊝
low2,3

200 per 10001734 per 1000
(348 to 1000)

Long-term improvement in pain and/or paraesthesia (six months follow-up)

Scale from: zero to 10
The mean improvement in pain and/or paraesthesia (six months follow-up) in the control group was 2.92The mean improvement in pain and/or paraesthesia (six months follow-up) in the intervention groups was
1.86 lower
(2.67 to 1.05 lower)
60
(1 study)
⊕⊕⊝⊝
low2,3

Long-term improvement in hand grip strength (six months follow-up)The mean improvement in hand grip strength (six months follow-up) in the control groups was 18.1 kilogramsThe mean improvement in hand grip strength (six months follow-up) in the intervention groups was
4.16 higher
(0.88 lower to 9.2 higher)
60
(1 study)
⊕⊕⊝⊝
low2,3

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Assumed risk is based on the risk in the control group in the one study comparing therapeutic ultrasound to placebo (Ebenbichler 1998).
2 Unit of analysis error committed.
3 Reasons for loss-to-follow-up not reported; not clear if participants were inappropriately excluded from the analyses.