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Greater pain relief and functional improvement with ESWT vs local corticosteroid for carpal tunnel
Study Type:Therapy
OE Level Evidence:1
Journal Level of Evidence:N/A
A randomized controlled trial: comparing extracorporeal shock wave therapy versus local corticosteroid injection for the treatment of carpal tunnel syndrome
Int Orthop. 2020 Jan;44(1):141-146.Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
Fifty-five patients with symptomatic carpal tunnel syndrome were randomized to receive 3 sessions of extracorporeal shockwave therapy (ESWT) over 3 weeks or a single ultrasound-guided local injection of corticosteroid. The outcomes of interest included pain on a Visual Analog Scale (VAS), the Boston Carpal Tunnel Questionnaire (BCTQ), as well as distal latency and amplitudes of the sensory nerve action potential (SNAP) and compound muscle action potential (CMAP). Follow up was performed 3, 9 and 12 weeks following the completion of treatment. Results showed significantly favourable VAS pain scores and BCTQ scores in the ESWT group compared to the corticosteroid group at 9 and 12 weeks post-treatment. With the exception of SNAP distal latency at 12 weeks, which was significantly in favour of the ESWT group, there were no significant differences between the two groups in SNAP or CMAP distal latency or amplitude outcomes, at all time-points.
Publication Funding Details
Funding
Unclear
Funding Details
Not reported.
Disclosures
N/A
Why was this study needed now?
Carpal tunnel syndrome is a condition caused by pressure on the median nerve resulting in pain, numbness and often functional deficit. Whilst surgical treatment options are available, conservative treatments such as local corticosteroid injection are commonly performed in mild to moderate cases. The use of extracorporeal shockwave therapy (ESWT) for carpal tunnel syndrome has been suggested to improve nerve recovery and restore neurophysiological states altered in carpal tunnel syndrome. The aim of this study was to compare ESWT and local corticosteroid injection for the treatment of carpal tunnel syndrome.
What was the principal research question?
How does extracorporeal shockwave therapy compare to ultrasound-guided local corticosteroid injection for the treatment of carpal tunnel syndrome with regards to pain, functional and nerve recovery outcomes up to 12 weeks post-operation?
What were the important study characteristics?
Population
55
Total Sample Size
Patients aged 20-60 with symptomatic carpal tunnel syndrome diagnosed by a physical medicine specialist.
Intervention
30
Extracorporeal Shock Wave Therapy
Patients received one session of ESWT per week on the affected wrist for 3 weeks, consisting of 1000 shocks with 1.5bar of pressure at a frequency of 6Hz
Comparison
25
Ultrasonography-Guided Corticosteroid Injections
Following anesthetization with 1mL lidocaine, patients received an ultrasound-guided injection of 1mL betamethasone into the region surrounding the median nerve.
Outcomes
Visual analogue scale (VAS)
Pain
Lower = Better
0.0-10.0
Boston Carpal Tunnel Questionnaire (BCTQ)
Function
Lower = Better
Sensory nerve action potential (SNAP) distal latency
Neurological
Lower = Better
Sensory nerve action potential (SNAP) amplitude
Neurological
Lower = Better
Compound muscle action potential (CMAP) distal latency
Neurological
Lower = Better
Compound muscle action potential (CMAP) amplitude
Neurological
Lower = Better
Methods
RCT
Randomized Controlled Trial
Single-Centered
Locations: China
Time
Baseline
Outcomes: Function, Neurological, Pain
3 Weeks
Outcomes: Function, Neurological, Pain
9 Weeks
Outcomes: Function, Neurological, Pain
12 Weeks
Outcomes: Function, Neurological, Pain
What were the important findings?
With the exception of the sensory nerve action potential (SNAP) distal latency time at 12 weeks, which was significantly lower in the ESWT group, there were not significant differences in SNAP and compound muscle action potential (CMAP) distal latency or amplitude outcomes at all time-points between the two groups.
Significantly Better
No Difference
Significantly Better
Extracorporeal Shock Wave Therapy
Ultrasonography-Guided Corticosteroid Injections
Pain
Risk of Bias
Mean (0-10, Lower = Better)
Visual analogue scale (VAS)
3 Weeks
Risk of Bias
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Overall risk of bias
Mean (0-10, Lower = Better)
Visual analogue scale (VAS)
9 Weeks
Risk of Bias
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Overall risk of bias
Mean (0-10, Lower = Better)
Visual analogue scale (VAS)
12 Weeks
Risk of Bias
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Overall risk of bias
Function
Risk of Bias
Mean (Lower = Better)
Boston Carpal Tunnel Questionnaire (BCTQ)
3 Weeks
Risk of Bias
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Overall risk of bias
Mean (Lower = Better)
Boston Carpal Tunnel Questionnaire (BCTQ)
9 Weeks
Risk of Bias
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Overall risk of bias
Mean (Lower = Better)
Boston Carpal Tunnel Questionnaire (BCTQ)
12 Weeks
Risk of Bias
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Overall risk of bias
High Risk of Bias
Some Concern
Low Risk of Bias
What should I remember most and how will this affect the care of my patients?
Study findings suggest that 3 sessions of extracorporeal shockwave therapy may provide significantly greater pain relief and functional improvement compared to a single injection of corticosteroid for the treatment of carpal tunnel syndrome. However, nerve recovery does not appear to be significantly different between the two groups. This study was limited by the short follow up as well as the lack of median nerve measurement with MRI due to cost and logistics.
The authors responsible for this critical appraisal and ACE Report indicate no potential conflicts of interest relating to the content in the original publication.