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Physicaltherapyscience.com- News - Physical Therapy reduces conversion to surgery for carpel syndrome: a multicenter randomized trial

Physical Therapy reduces conversion to surgery for carpel syndrome: a multicenter randomized trial

27-04-2020

Background: 
It was demonstrated in Netherlands that the prevalence of electrophysiological confirmed CTS in the adult population was estimated by 0.6%   in men and 3.4 %in women by 2006. Carpal tunnel syndrome (CTS) is defined as a neuropathy caused by compression and traction of the median nerve at the level of the carpal tunnel, delimitated by the carpal bones and by the transverse carpal ligament. It was known from previous studies that Carpal tunnel release is more cost-effective compared with splinting, and recommended as the preferred method of treatment for patients with CTS. However, according to a study that was performed in Australia where Participants were recruited from different four publically hospitals, where one hundred and five patients were divided into experimental and control groups, It was concluded that A therapist-led pathway reduced conversion to carpal tunnel surgery and increased perceived improvement and satisfaction in people who were already on a waitlist for surgical consultation.

Introduction:
Carpal tunnel syndrome is the most well-known and frequent form of median nerve neuropathy, and accounts for 90% of all neuropathies. It affects the middle ages of 40-60 years. Although most cases of CTS is idiopathic and mainly due to a fibrous hypertrophy of the synovial flexor sheath, by time the patients get paresthesia, pain, weakness and loss of dexterity with the repetitive movement of the wrist in the affected hand. .Although there are several risk factors associated with CTS (such as age, diabetes and sex) in many cases, there is no obvious comorbidity. CTS is associated with a significant socioeconomic burden due to its impact on productivity, function, quality of life and significant costs associated with its management.   Annual costs of surgery are estimated at more than US$ 2 billion in the United States. Available data suggested that the waitlists for CTS surgery are long, ranging from 2 to 10 months, with many countries in Northern America, Europe and Australia having wait times more than5 months.

Method:
A multi-center randomized controlled trial was demonstrated among 105 of people with a clinical diagnosis of CTS confirmed by nerve conduction studies and who were referred by their general practitioner to the waiting list for surgical consultation at each of four hospitals in Queensland (Queen Elizabeth II Jubilee Hospital Brisbane, Rockhampton Hospital, Logan Hospital, Gold Coast University Hospital). All patients suffered from bilateral CTS, while this study including the assessment was carried out on one only affected hand (The right one).The participants were selected from both sexes. All subjects underwent to inclusive criteria and exclusive criteria.
 
Inclusive criteria:
  • Their age ranged between 18 and 75years.
  • having experienced symptoms for 2months
  • Ability to comprehend the requirements of the study.
Exclusive criteria:
  • Osteoarthritis of the wrist or hand
  • Other musculoskeletal or neurological conditions affecting the upper limb (e.g., trigger finger, cervical radiculopathy.
  • CTS related to trauma
  •  Systemic diseases (other than diabetes) or pregnancy.
  • People who had received a steroid injection within the previous 6 month.
  • Hand therapy intervention (splinting or exercises) within the previous 3 month.
Study Design
105 participants were assigned into2 groups (an experimental and controlled group).The study was conducted for 24 weeks and both groups Participants’ were reassessed 6 and 24 weeks later after the start of study conduction.

The experimental group
52 individual received a one-off group session of education, splinting, and nerve and tendon gliding exercises during a single group for30 minutes and then continued as a home-based program.
  • a presentation and booklet regarding CT pathophysiology and treatment options (conservative management and surgery)
  • posture and activity modification principles:
  • Decrease or change activities that require repetitive bending of the wrist
  • Try to avoid keeping the wrist bent forwards or backwards for long period particularly if pinching or gripping at the same time.
  • There is more room in the carpal tunnel when the wrist is straight.
  • Loosen the grip and change the wrist position regularly eg. When reading a book, talking on the phone, pushing a shopping trolley or sweeping/mopping.
  • Take regular breaks during activities.
  • A home exercise program consisting of median nerve-gliding and tendon-gliding exercises.
  •  Providing a wrist orthosis with a custom palmar stay to position the wrist in a neutral position moreover subjects were advised to wear the splint during the night only.
  • Giving advices to change the surrounding environment for the patients.
 
The control group
53 individuals continued without receiving any additional care to be in the waiting list of the surgical consultation.
 
Measurement of the outcomes and Material
During the initial appointment (Week 0), the medical history, demographic data, electro diagnostic test severity and baseline data were collected. Outcome measures were collected at Weeks 6 and 24 by a local trial clinician who was blinded to group allocation. At Week 24, participants also attended a consultation with an orthopedic surgeon. 

Primary measures outcome and used scales
  • The conversion to surgery was measured by the global rating of change (GROC) scale.
  • Participants’ satisfaction with treatment, function and overall progress was collected using a satisfaction questionnaire.  
Secondary measures outcome and used scales
  • Participants’ symptom severity was assessed by:
  • The Symptom Severity Scale of the Boston CTS Questionnaire
  • The self-report version of the Leeds Assessment of Neuropathic Symptoms and Signs scale (S-LANSS).
  • Participants’ functional limitations were assessed by
  • DASH scale
  • The Patient-Specific Functional Scale (PSFS).
  • Symptom distribution was assessed with a hand and body diagram and interpreted by the scale of Katz, with a specific focus on patients with extra-median spread and/or proximal spread of symptoms.
 
Results and effects of intervention on the outcomes

The primary outcomes
  • The percentage of participants who converted to surgery was 59% in the experimental group while it was 80% in the control group. At Week 6, the proportion of participants who reported a GROC was 20% in the experimental group and 4% in the control group but at week 24 was less beneficial.
  • The experimental intervention was also beneficial on the patients’ satisfaction score where it was estimated as 95% at Week 6 and the same at Week 24.
 
The secondary outcomes
  • The effect of the experimental intervention on the Symptom Severity Scale of the Boston CTS Questionnaire at Week 6 was estimated as a reduction in severity of symptoms that was reported as 95% with similar estimate at Week 24.
  • The effect of the experimental intervention on the S-LANSS might be beneficial by 1 to 2 points on the 0-to-24 scale. However, there was indication of uncertainty about the true average effect of the treatment on this outcome.
  • There were mixed results among the three measures of functional limitation.
  • The Functional Status Scale of the Boston CTS Questionnaire had favorable mean estimates, with indicating uncertainty about the true average effect of the treatment.
  • On the DASH, the estimate at Week 6 favored the experimental intervention but the estimate at Week 24 was weaker and included the possibility of no effect.
  • On the PSFS, the estimate at both time points was that the experimental intervention improved function by about 1 point on the 0-to-10 scale.
  • The estimate of the experimental intervention’s effect on the likelihood of symptoms occurring outside median nerve territory was a reduction of almost 20%.
  • The estimate of the effect of the experimental intervention on the likelihood of symptoms occurring proximal to the wrist was less clear.

Discussion
The main estimates produced by this study are that the therapist led program of education, splinting and home exercises: reduces the likelihood of proceeding to surgery 24 weeks later by 21%; increases the likelihood of patients reporting a successful improvement at 6 weeks by 15%; and improves the combined satisfaction score by just over 10 points at both time points.
The most favorable limits seemed to outweigh the inconveniences of the intervention for the primary outcomes. Similarly, most secondary outcome measures favored the experimental intervention over the control group including several aspects of patient satisfaction, the Symptom Severity Scale of the Boston Questionnaire, the DASH and the PSFS. However, it could not be sure that the average effect of the intervention in the wider population of people waitlisted for CTS surgery is clinically worthwhile on most of these secondary outcomes.

Conclusion
It was concluded from this study that a combination of education, night splinting and home exercises reduced progression to surgery and increased perceived improvement and satisfaction in people awaiting carpel tunnel surgery. Moreover, more studies are recommended to measure the magnitude of these benefits in the wider population of this category of patients.

References
  • Lewis K;et al. Group education, night splinting and home exercises reduce conversion to surgery for carpal tunnel syndrome: a multicenter randomized trial. Physiotherapy J.2020; 03:007.
  • Aroori S, Spence RA. Carpal tunnel syndrome. Ulster Med J. 2008; 77:6–17. 
  • https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-7-86.

Dr. A. Masioud
senior physical therapist Ministery of Health and Population Egypt
member Physical Therapy & Science Assocation



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