Bionka M. A. Huisstede

Carpal Tunnel Syndrome. Part I: Effectiveness of Nonsurgical Treatments–A Systematic Review

OBJECTIVE To review literature systematically concerning effectiveness of nonsurgical interventions for treating carpal tunnel syndrome (CTS). DATA SOURCES The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs). STUDY SELECTION Two reviewers independently applied the inclusion criteria to select potential studies. DATA EXTRACTION Two reviewers independently extracted the data and assessed the methodologic quality. DATA SYNTHESIS A best-evidence synthesis was performed to summarize the results of the included studies. Two reviews and 20 RCTs were included. Strong and moderate evidence was found for the effectiveness of oral steroids, steroid injections, ultrasound, electromagnetic field therapy, nocturnal splinting, and the use of ergonomic keyboards compared with a standard keyboard, and traditional cupping versus heat pads in the short term. Also, moderate evidence was found for ultrasound in the midterm. With the exception of oral and steroid injections, no long-term results were reported for any of these treatments. No evidence was found for the effectiveness of oral steroids in long term. Moreover, although higher doses of steroid injections seem to be more effective in the midterm, the benefits of steroids injections were not maintained in the long term. For all other nonsurgical interventions studied, only limited or no evidence was found. CONCLUSIONS The reviewed evidence supports that a number of nonsurgical interventions benefit CTS in the short term, but there is sparse evidence on the midterm and long-term effectiveness of these interventions. Therefore, future studies should concentrate not only on short-term but also on midterm and long-term results.

Multidisciplinary consensus on the terminology and classification of complaints of the arm, neck and/or shoulder

Background: There is no universally accepted way of labelling or defining upper-extremity musculoskeletal disorders. A variety of names are used and many different classification systems have been introduced. Objective: To agree on an “unambiguous language” concerning the terminology and classification that can be used by all relevant medical and paramedical disciplines in the Netherlands. Methods: A Delphi consensus strategy was initiated. The outcomes of a multidisciplinary conference were used as a starting point. In total, 47 experts in the field of upper-extremity musculoskeletal disorders were delegated by 11 medical and paramedical professional associations to form the expert panel for the Delphi consensus strategy. Each Delphi round consisted of a questionnaire, an analysis and a feedback report. Results: After three Delphi rounds, consensus was achieved. The experts reported the consensus in a model. This so-called CANS model describes the term, definition and classification of complaints of arm, neck and/or shoulder (CANS) and helps professionals to classify patients unambiguously. CANS is defined as “musculoskeletal complaints of arm, neck and/or shoulder not caused by acute trauma or by any systemic disease”. The experts classified 23 disorders as specific CANS, because they were judged as diagnosable disorders. All other complaints were called non-specific CANS. In addition, the experts defined “alert symptoms” on the top of the model. Conclusions: The use of the CANS model can increase accurate and meaningful communication among healthcare workers, and may also have a positive influence on the quality of scientific research, by enabling comparison of data of different studies.

Incidence and prevalence of upper-extremity musculoskeletal disorders. A systematic appraisal of the literature

BackgroundA systematic appraisal of the worldwide incidence and prevalence rates of UEDs available in scientific literature was executed to gauge the range of these estimates in various countries and to determine whether the rates are increasing in time.MethodsStudies that recruited at least 500 people, collected data by using questionnaires, interviews and/or physical examinations, and reported incidence or prevalence rates of the whole upper-extremity including neck, were included.ResultsNo studies were found with regard to the incidence of UEDs and 13 studies that reported prevalence rates of UEDs were included. The point prevalence ranged from 1.6–53%; the 12-months prevalence ranged from 2.3–41%. One study reported on the lifetime prevalence (29%). We did not find evidence of a clear increasing or decreasing pattern over time. The case definitions for UEDs used in the studies, differed enormously. Therefore, it was not possible to pool the data.ConclusionThere are substantial differences in reported prevalence rates on UEDs. Main reason for this is the absence of a universally accepted way of labelling or defining UEDs. If we want to make progress in this field, the first requirement is to agree on unambiguous terminology and classification of EUDs.

Prevalence and Characteristics of Complaints of the Arm, Neck, and/or Shoulder (CANS) in the Open Population

ObjectiveTo study the prevalence of upper extremity disorders (UEDs) and neck as a total and complaints of the arm, neck and/or shoulder (CANS) not caused by acute trauma or any systemic disease as defined in the CANS model in the open population and to assess sociodemographic and health characteristics of chronic symptoms. MethodsData were obtained from the DMC3-study, a Dutch questionnaire survey on musculoskeletal conditions (>25 y, n=3664). Data on four anatomic sites were assessed: neck, shoulder, elbow, and wrist. Various health characteristics were measured including the Short Form-36. Rectangle diagrams were used to illustrate cooccurrence of pain in the four anatomic sites. ResultsThe 12-month prevalence of CANS was 36.8%, the point prevalence was 26.4%, and 19.0% patients reported chronic CANS. Women, aged 45 to 64 years, with the lowest education level and working were the most affected. Within those with UEDs, around 25% of cases were caused by an acute trauma or by some systemic disease. Of those with chronic CANS, 58% reported use of healthcare. Healthcare users scored worse on general health, limitations in daily living, pain, and sickness absence than nonhealthcare users; >43% reported symptoms in more than 1 anatomic site. DiscussionUEDs and CANS frequently occur in the open population. Excluding acute traumas and systemic diseases reduced the prevalence of CANS and resulted in a relatively healthier population. A compound definition of CANS seems indicated because of the large overlap of affected anatomic sites.

Carpal Tunnel Syndrome. Part II: Effectiveness of Surgical Treatments—A Systematic Review

OBJECTIVE To present an evidence-based overview of the effectiveness of surgical and postsurgical interventions to treat carpal tunnel syndrome (CTS). DATA SOURCES The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs). STUDY SELECTION Two reviewers independently applied the inclusion criteria to select potential studies. DATA EXTRACTION Two reviewers independently extracted the data and assessed the methodologic quality. DATA SYNTHESIS A best-evidence synthesis was performed to summarize the results of the included studies. Two reviews and 25 RCTs were included. Moderate evidence was found in favor of surgical treatment compared with splinting or anti-inflammatory drugs plus hand therapy in the midterm and long term, and for the effectiveness of corticosteroid irrigation of the median nerve before skin closure as additive to carpal tunnel release in the short term. Limited evidence was found in favor of a double-incision technique compared with the standard incision technique. Also, limited evidence was found in favor of a mini-open technique assisted by a Knifelight instrument compared with a standard open release at 19 months of follow-up. However, in the short term and at 30 months of follow-up, no significant differences were found between the mini-open technique assisted by a Knifelight instrument compared with a standard open release. Many studies compared different surgical interventions, but no evidence was found in favor of any one of them. No RCTs explored the optimal timing strategy for surgery. No evidence was found for the efficacy of various presurgical or postsurgical treatment programs, including splinting. CONCLUSIONS Surgical treatment seems to be more effective than splinting or anti-inflammatory drugs plus hand therapy in the midterm and long term to treat CTS. However, there is no unequivocal evidence that suggests one surgical treatment is more effective than the other. More research is needed to study conservative to surgical treatment in which also should be taken into account the optimal timing of surgery. Future research should also concentrate on optimal presurgical and postsurgical treatment programs.

Evidence for effectiveness of Extracorporal Shock-Wave Therapy (ESWT) to treat calcific and non-calcific rotator cuff tendinosis--a systematic review.

Extracorporeal shock-wave therapy (ESWT) is suggested as a treatment alternative for calcific and non-calcific rotator cuff tendinosis (RC-tendinosis), which may decrease the need for surgery. In this study we assessed the evidence for effectiveness of ESWT for these disorders. The Cochrane Library, PubMed, Embase, Pedro, and Cinahl were searched for relevant systematic reviews and RCTs. Two reviewers independently extracted data and assessed the methodological quality. Seventeen RCTs (11 calcific, 6 non-calcific) were included. For calcific RC-tendinosis, strong evidence was found for effectiveness in favour of high-ESWT versus low-ESWT in short-term. Moderate evidence was found in favour of high-ESWT versus placebo in short-, mid- and long-term and versus low-ESWT in mid- and long-term. Moreover, high-ESWT was more effective (moderate evidence) with focus on calcific deposit versus focus on tuberculum major in short- and long-term. RSWT was more effective (moderate evidence) than placebo in mid-term. For non-calcific RC-tendinosis, no strong or moderate evidence was found in favour of low-, mid- or high-ESWT versus placebo, each other, or other treatments. This review shows that only high-ESWT is effective for treating calcific RC-tendinosis. No evidence was found for the effectiveness of ESWT to treat non-calcific RC-tendinosis.

Interventions for Treating the Radial Tunnel Syndrome: A Systematic Review of Observational Studies

PURPOSE For some disorders, such as radial tunnel syndrome (RTS), no randomized controlled trials and controlled clinical trials are available. To gain insight into the effectiveness of conservative and surgical interventions for treating RTS, we systematically reviewed all available observational studies on treatment of RTS. Although the validity of case series is inferior to that of controlled trials, the case series might provide valuable data about the efficacy of treatment options. METHODS A literature search and additional reference checking resulted in 21 eligible case series for this review. Based on previous checklists, we constructed a new quality assessment and rating system to analyze the included case series. The methodological quality was assessed, and data extraction was performed. Studies with less than 50% of the maximum points on the methodological quality assessment were considered inadequate and were excluded from the analysis. To summarize the results according to the rating system for the strength of the scientific evidence for these case series, we introduced 4 levels: (1) tendency, (2) slight tendency, (3) conflicting tendency, and (4) no tendency. RESULTS After the methodological quality assessment, 6 articles were included in the final analysis. They all reported on surgical treatment. CONCLUSIONS There is a tendency that surgical decompression of the radial tunnel might be effective in patients with RTS. The effectiveness of conservative treatments for RTS is unknown because, for most treatments, no studies were available. Additional high-quality controlled studies are needed to assess the level of conclusive evidence for surgical treatment and also to evaluate conservative treatments for RTS. For this, we recommend a multicenter, randomized clinical trial. Due to the lack of a clear protocol for diagnosing RTS, a reliable and valid diagnostic tool should be developed. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Effectiveness of Surgical and Postsurgical Interventions for the Subacromial Impingement Syndrome: A Systematic Review

OBJECTIVE To provide an evidence-based overview of the effectiveness of surgical and postsurgical interventions for the subacromial impingement syndrome. DATA SOURCES The Cochrane Library, PubMed, Embase, PEDro, and CINAHL were searched. STUDY SELECTION Two reviewers independently selected relevant systematic reviews and randomized controlled trials (RCTs). DATA EXTRACTION Two reviewers independently extracted data and assessed the methodologic quality. DATA SYNTHESIS If pooling of data was not possible, a best-evidence synthesis was used to summarize the results. RESULTS One review and 5 RCTs reporting on various surgical techniques, and postsurgical interventions were included. Moderate evidence was found in favor of adding platelet-leukocyte gel versus open subacromial decompression. No evidence was found for the superiority of subacromial decompression versus conservative treatment in the short, mid, and long term or in favor of 1 surgical technique when compared with another. Limited evidence was found in favor of early activation after arthroscopic decompression in the short and long term. CONCLUSIONS This review shows that there is no evidence that surgical treatment is superior to conservative treatment or that 1 particular surgical technique is superior to another. Because of possibly lower risks for complications, conservative treatment may be preferred. When choosing for surgery, arthroscopic decompression may be preferred because of the less invasive character of the procedure.

Subacromial impingement syndrome—effectiveness of physiotherapy and manual therapy

Background The subacromial impingement syndrome (SIS) includes the rotator cuff syndrome, tendonitis and bursitis of the shoulder. Treatment includes surgical and non-surgical modalities. Non-surgical treatment is used to reduce pain, to decrease the subacromial inflammation, to heal the compromised rotator cuff and to restore satisfactory function of the shoulder. To select the most appropriate non-surgical intervention and to identify gaps in scientific knowledge, we explored the effectiveness of the interventions used, concentrating on the effectiveness of physiotherapy and manual therapy. Methods The Cochrane Library, PubMed, EMBASE, PEDro and CINAHL were searched for relevant systematic reviews and randomised clinical trials (RCTs). Two reviewers independently extracted data and assessed the methodological quality. A best-evidence synthesis was used to summarise the results. Results Two reviews and 10 RCTs were included. One RCT studied manual therapy as an add-on therapy to self-training. All other studies studied the effect of physiotherapy: effectiveness of exercise therapy, mobilisation as an add-on therapy to exercises, ultrasound, laser and pulsed electromagnetic field. Moderate evidence was found for the effectiveness of hyperthermia compared to exercise therapy or ultrasound in the short term. Hyperthermia and exercise therapy were more effective in comparison to controls or placebo in the short term (moderate evidence). For the effectiveness of hyperthermia, no midterm or long-term results were studied. In the midterm, exercise therapy gave the best results (moderate evidence) compared to placebo or controls. For other interventions, conflicting, limited or no evidence was found. Conclusions Some physiotherapeutic treatments seem to be promising (moderate evidence) to treat SIS, but more research is needed before firm conclusions can be drawn.

Evidence for the effectiveness of electrophysical modalities for treatment of medial and lateral epicondylitis: a systematic review

Background Several treatments are available to treat epicondylitis. Among these are instrumental electrophysical modalities, ranging from ultrasound, extracorporeal shock wave therapy (ESWT), transcutaneous electrical nerve stimulation (TENS) to laser therapy, commonly used to treat epicondylitis. Objectives To present an evidence-based overview of the effectiveness of electrophysical modality treatments for both medial and lateral epicondylitis (LE). Methods Searches in PubMed, EMBASE, CINAHL and Pedro were performed to identify relevant randomised clinical trials (RCTs) and systematic reviews. Two reviewers independently extracted data and assessed the methodological quality. A best-evidence synthesis was used to summarise the results. Results A total of 2 reviews and 20 RCTs were included, all of which concerned LE. Different electrophysical regimes were evaluated: ultrasound, laser, electrotherapy, ESWT, TENS and pulsed electromagnetic field therapy. Moderate evidence was found for the effectiveness of ultrasound versus placebo on mid-term follow-up. Ultrasound plus friction massage showed moderate evidence of effectiveness versus laser therapy on short-term follow-up. On the contrary, moderate evidence was found in favour of laser therapy over plyometric exercises on short-term follow-up. For all other modalities only limited/conflicting evidence for effectiveness or evidence of no difference in effect was found. Conclusions Potential effectiveness of ultrasound and laser for the management of LE was found. To draw more definite conclusions high-quality RCTs examining different intensities are needed as well as studies focusing on long-term follow-up results.