Peter Hoogvliet

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.

A model for the relation between the displacement of the ankle and the center of pressure in the frontal plane, during one-leg stance

We present and validate a model for the relation between the horizontal, frontal plane displacement of the ankle, representing frontal plane foot tilt, and the frontal plane displacement of the Center of Pressure (CoP) during one-leg stance. It is concluded that the frontal plane movements of the CoP should be regarded not as a measure of body sway, as is often done, but as a measure for the tilting movements of the foot as a mechanism for balance control. Foot breadth affects the gain of this mechanism in terms of CoP displacement and can potentially affect balance control.

Carpal Tunnel Syndrome: Hand Surgeons, Hand Therapists, and Physical Medicine and Rehabilitation Physicians Agree on a Multidisciplinary Treatment Guideline—Results From the European HANDGUIDE Study

OBJECTIVE To achieve consensus on a multidisciplinary treatment guideline for carpal tunnel syndrome (CTS). DESIGN Delphi consensus strategy. SETTING Systematic reviews reporting on the effectiveness of surgical and nonsurgical interventions were conducted and used as an evidence-based starting point for a European Delphi consensus strategy. PARTICIPANTS In total, 35 experts (hand surgeons selected from the Federation of European Societies for Surgery of the Hand, hand therapists selected from the European Federation of Societies for Hand Therapy, physical medicine and rehabilitation physicians) participated in the Delphi consensus strategy. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Each Delphi round consisted of a questionnaire, analysis, and feedback report. RESULTS After 3 Delphi rounds, consensus was achieved on the description, symptoms, and diagnosis of CTS. The experts agreed that patients with CTS should always be instructed, and instructions combined with splinting, corticosteroid injection, corticosteroid injections plus splinting, and surgery are suitable treatments for CTS. Relevant details for the use of instructions, splinting, corticosteroid injections, and surgery were described. Main factors for selecting one of the aforementioned treatment options were identified as follows: severity and duration of the disorder and previous treatments received. A relation between the severity/duration and choice of therapy was found by the experts and reported in the guideline. CONCLUSIONS This multidisciplinary treatment guideline may help physicians and allied health care professionals to provide patients with CTS with the most effective and efficient treatment available.

Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review

Background Owing to the change in paradigm of the histological nature of epicondylitis, therapeutic modalities as exercises such as stretching and eccentric loading and mobilisation are considered for its treatment. Objective To assess the evidence for effectiveness of exercise therapy and mobilisation techniques for both medial and lateral epicondylitis. 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. Results One review and 12 RCTs, all studying lateral epicondylitis, were included. Different therapeutic regimes were evaluated: stretching, strengthening, concentric/eccentric exercises and manipulation of the cervical or thoracic spine, elbow or wrist. No statistical pooling of the results could be performed owing to heterogeneity of the included studies. Therefore, a best-evidence synthesis was used to summarise the results. Moderate evidence for the short-term effectiveness was found in favour of stretching plus strengthening exercises versus ultrasound plus friction massage. Moderate evidence for short-term and mid-term effectiveness was found for the manipulation of the cervical and thoracic spine as add-on therapy to concentric and eccentric stretching plus mobilisation of wrist and forearm. For all other interventions only limited, conflicting or no evidence was found. Conclusions Although not yet conclusive, these results support the belief that strength training decreases symptoms in tendinosis. The short-term analgesic effect of manipulation techniques may allow more vigorous stretching and strengthening exercises resulting in a better and faster recovery process of the affected tendon in lateral epicondylitis.

Effectiveness of interventions for secondary Raynaud's phenomenon: a systematic review.

OBJECTIVES To present an evidence-based overview of the effectiveness of (non)surgical symptomatic interventions to treat secondary Raynauds phenomenon (RP). DATA SOURCES The Cochrane Library, PubMed, Embase, PEDro, and CINAHL 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 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. Of the 5 reviews and 19 RCTs included, 1 RCT studied acupuncture and another RCT reported on percutaneous radiofrequency thoracic sympathectomy. All others concentrated on the effectiveness of drugs (oral or intravenous [IV]). It appeared that calcium channel blockers significantly reduce the frequency and severity of Raynaud attacks, and are therefore effective in the treatment of secondary RP. Iloprost (oral and IV) was also found to be effective. Limited evidence was found for atorvastatin. For other traditional and more recently discovered interventions, no clear favorable effects were found. CONCLUSIONS This review shows that there is clear evidence in favor of calcium channel blockers and iloprost (oral and IV) to treat secondary RP. For all other interventions, only limited, conflicting, or no evidence was found. More high-quality, well-designed RCTs are needed in this field, especially for new interventions based on recent knowledge about the pathophysiology of secondary RP.

Variations in Foot Breadth: Effect on Aspects of Postural Control During One-Leg Stance

OBJECTIVE To test the hypothesis that changing body weight toward the narrower rearfoot or the wider forefoot causes a decrease or increase in the amount of center of pressure (CoP) displacement per unit of foot tilt (EQ), and to examine the effect on postural control. DESIGN Experimental, within-subject design with one controlled variable. SETTING A biomechanics laboratory of a university department of biomedical physics and technology. SUBJECTS Ten healthy, young subjects. MAIN OUTCOME MEASURES The sagittal plane position of the CoP (Y) reflecting foot loading, EQ, and horizontal ground reaction forces (Fx) representing postural control. RESULTS Shifting body weight to the rearfoot or forefoot decreases (d) or increases (i) Y (Pd = .002, Pi = .000) and EQ (Pd = .018, Pi = .064). In both cases Fx (Pd = .008, Pi = .098) increased and postural control deteriorated. CONCLUSIONS Shifting body weight to the rearfoot or forefoot decreases or increases EQ. Besides the changes in EQ encountered here, other factors are held responsible for the deterioration of postural control. The absence or presence of changes in Y can be used to exclude or include the presence of an effect of EQ or these unknown factors on postural control.

How to treat Guyon's canal syndrome? Results from the European HANDGUIDE study: a multidisciplinary treatment guideline

Background Although Guyons canal syndrome is not highly prevalent, a considerable knowledge of anatomy is needed to localise and treat the pathology. Data on the effectiveness of interventions for this disorder are lacking. Objective To achieve consensus on a multidisciplinary treatment guideline for this disorder based on experts’ opinions. Methods A European Delphi consensus strategy was initiated. In total, 35 experts (hand surgeons/hand therapists selected by the national member associations of their European federations and Physical Medicine and Rehabilitation physicians) participated in 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 on the description, symptoms and diagnosis of Guyons canal syndrome. The experts agreed that patients with this disorder should always receive instructions and that these instructions should be combined with another form of treatment. Instructions combined with splinting or with surgery were considered as suitable treatment options. Details on the use of instructions, splinting and surgery were described. Main factors for selecting one of the aforementioned treatment options were identified: severity and duration of the syndrome and previous treatments given. A relation between the severity/duration and choice of therapy was indicated by the experts and reported in the guideline. Conclusions Although this disorder is less prevalent and not easy to diagnose, this guideline may contribute to better insight into and treatment of Guyons canal syndrome.

Dupuytren disease : european hand surgeons, hand therapists, and physical medicine and rehabilitation physicians agree on a multidisciplinary treatment guideline: results from the HANDGUIDE Study

Background: Multidisciplinary treatment guidelines for Dupuytren disease can aid in optimizing the quality of care for patients with this disorder. Therefore, this study aimed to achieve consensus on a multidisciplinary treatment guideline for Dupuytren disease. Methods: A European Delphi consensus strategy was initiated. A systematic review reporting on the effectiveness of interventions was conducted and used as an evidence-based starting point for this study. In total, 39 experts (hand surgeons, hand therapists, and physical medicine and rehabilitation physicians) participated in the Delphi consensus strategy. Each Delphi round consisted of a questionnaire, an analysis, and a feedback report. Results: After four Delphi rounds, consensus was achieved on the description, symptoms, and diagnosis of Dupuytren disease. No nonsurgical interventions were included in the guideline. Needle and open fasciotomy, and a limited fasciectomy and dermofasciectomy, were seen as suitable surgical techniques for Dupuytren disease. Factors relevant for choosing one of these surgical techniques were identified and divided into patient-related (age, comorbidity), disease-related (palpable cord, previous surgery in the same area, skin involvement, time of recovery, recurrences), and surgeon-related (years of experience) factors. Associations of these factors with the choice of a specific surgical technique were reported in the guideline. Postsurgical rehabilitation should always include instructions and exercise therapy; postsurgical splinting should be performed on indication. Relevant details for the use of surgical and postsurgical interventions were described. Conclusion: This treatment guideline is likely to promote further discussion on related clinical and scientific issues and may therefore contribute to better treatment of patients with Dupuytren disease.

Effectiveness of Oral Pain Medication and Corticosteroid Injections for Carpal Tunnel Syndrome: A Systematic Review

OBJECTIVE To present an evidence-based overview of the effectiveness of oral pain medication and corticosteroid injections to treat carpal tunnel syndrome (CTS). DATA SOURCES The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database 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 on pain (visual analog scale), function or recovery, and assessed the methodologic quality. DATA SYNTHESIS A best-evidence synthesis was performed to summarize the results of the included studies. Four reviews and 9 RCTs were included. For oral pain medication, strong and moderate evidence was found for the effectiveness of oral steroids versus placebo in the short term. Moderate evidence was found in favor of oral steroids versus splinting in the short term. No evidence was found for the effectiveness of oral steroids in the long term. For corticosteroid injections, strong evidence was found in favor of a corticosteroid injection versus a placebo injection and moderate evidence was found in favor of corticosteroid injection versus oral steroids in the short term. Also, in the short term, moderate evidence was found in favor of a local versus a systematic corticosteroid injection. Higher doses of corticosteroid injections seem to be more effective in the midterm; however, the benefits of corticosteroid injections were not maintained in the long term. CONCLUSIONS The reviewed evidence supports that oral steroids and corticosteroid injections benefit patient with CTS particularly in the short term. Although a higher dose of steroid injections seems to be more effective in the midterm, the benefits of oral pain medication and corticosteroid injections were not maintained in the long term.