Introduction:

Carpal Tunnel Syndrome (CTS) is caused by compression of the median nerve within the carpal tunnel of the hand and wrist. Compression can be caused by overuse of the wrist and digital flexors. This sort of overuse can occur in people with occupations requiring mechanical wrist motions i.e. construction, typing, texting, etc. CTS can also occur with weight gain, water retention, and pregnancy which is why this diagnosis is more common in women than men. It can be diagnosed clinically with a number of special tests, but the gold standard for diagnosis is electromyography (EMG) testing. The diagnosis is then typically categorized into mild, moderate, or severe.

Clinical Scenario:

The patient is a 55 year old female registered nurse with 1 year history of mild right wrist pain and numbness in her first 3 digits. She has been self-managing with a wrist brace she bought at a local pharmacy, which has helped decrease her pain. In the last 6 weeks, however, her pain has gotten worse after she spent all day cooking a large meal for her family. The brace no longer eases the pain, which is now at a 7/10 with activity. She hasn’t seen her physician because she is afraid of surgery, but believes physical therapy could help her.

Key Exam Findings:
– No pain with c/s ROM (neg. Spurlings, neg. Cervical distraction)
– Mild hyposensitivity in median nerve distribution
– Mild weakness in R thenar opposition to 5th digit
– No significant muscle wasting of thenar eminence
– ULNDT ROM R<L
– Positive Carpal Compression Test
– Positive Tinel’s Sign

Outcome Measures:
– NPRS: 7/10 pain with activity
– BCTQ Function: 23/40 (Moderate)
– BCTQ Symptom Severity: 28/55 (Moderate)

PICO: In adults with carpal tunnel syndrome, is surgery more effective than conservative treatment in improving pain and function?

Search Strategy:
Inclusion Criteria: (1) Adults >18 years who have been diagnosed with CTS clinically or with electro-diagnostics (2) At least one intervention that is non-surgical or conservative and can be performed by a physical therapist (3) At least one intervention that is considered surgical (4) At least one of the following outcome measures used: CTSAQ, BCTQ, NPRS
Exclusion Criteria: (1) Surgery compared solely to conservative treatment that cannot be administered by a physical therapist i.e. steroid injections

Appraisal Table:

Results:
* Only 3 out of the 5 articles studied outcomes in short term and long term follow-ups. Of the 2 that did not, one had a follow-up of 6 months³ and the other had a follow-up of 5 years⁴. I chose to include the 6 month follow-up in the short term and the 5 year follow-up in the long term. Thus, there are 4 articles that look at each the short term and the long term.

**The authors of the study that found results on function favoring surgery in the short term state that the results of that analysis are likely not clinically meaningful².
***All interventions studied on outcomes of both pain and function, in both the short term and the long term had positive significant within-group changes. This means that each intervention was associated with significant improvements over time.

Limitations:

• Definition of conservative treatment varied across the studies
• Generalizability:
  • Various populations studied
  • EMG used as an outcome measure
    • Two studies ^4,5 excluded people with normal EMG findings despite them having clinical symptoms
    • Ucan et. al. stated that 2 people included in their study had EMG improvements over time, but still had functional limitations and clinical symptoms⁵
  • Exclusion of those with severe CTS

Clinical Bottom Line:

There is limited and inconsistent evidence to conclude that surgery is more effective than conservative treatment on improving pain and function in adults with CTS. Because of this, it is suggested that conservative treatment, as it is effective, less-invasive, and less-costly, be the first line of management for this diagnosis.

Application to Case Scenario:

• Conservative Treatment¹: 30 minute sessions, 1x per week, for at least 3 weeks
  • Manual Therapy – directed at sites of potential entrapment of median nerve
    • Nerve/Tendon Gliding – 5-10 min. in 2 sets of 5 min. with 1 min. rest between
      
    • Lateral Glides to C-spine
    • Soft Tissue Mobilization – treated according to pain on palpation or reproduction of symptoms
      
  • Splinting/Rest – in neutral position, at night, for up to 6 weeks

References:

1. Fernandez-de-las Peñas C, et. al. Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial. The Journal of Pain. 2015; 16(11): 1087-1094.
2. Jarvik J, et. al. Surgery versus non-surgical therapy for carpal tunnel syndrome: a randomised parallel-group trial. Lancet. 2009; 374: 1074-1081.
3. Elwakil T, et. al. Treatment of carpal tunnel syndrome by low-level laser versus open carpal tunnel release. Lasers Med Sci. 2007; 22: 265-270.
4. Ettema A, et. al. Surgery versus Conservative Therapy in Carpal Tunnel Syndrome in People Aged 70 Years and Older. Plast. Reconstr. Surg. 2006; 118: 947.
5. Ucan H, et. al. Comparison of splinting, splinting plus local steroid injection and open carpal tunnel release outcomes in idiopathic carpal tunnel syndrome. Rheumatol Int. 2006; 27: 45-51.