Intuitively, the goals of treatment are to control symptoms, minimize motor impairment, maximize functional status (i.e. re-establish strength and function of muscles affected by impaired nerve conduction), and prevent future disability via occupational interventions. Unfortunately, patient's with WRCTS usually have poorer treatment outcomes2.
Effective management involves a multidisciplinary and interprofessional approach including the skills of a primary care physician (family or occupational medicine physician), occupational therapist, physical therapist, neurologist, physiatrist, plastic or othropaedic surgeon and others given the presence of systemic conditions. The role of the primary care physician is to establish the diagnosis, provide referrals as needed, coordinate and monitor the efficacy of medical treatment, and help ensure that appropriate workplace modifications are made.
The following is a suggested approach to the treatment of CTS based on the individual clinical presentation,
*No improvement is defined as lack of symptom or functional ability improvement following a one month trial of splinting and/or after receiving two or more corticosteroid injections in a twelve month period1. CC: chief complaint.
Image Source: Victoria Squissato
Patients with mild to moderate symptoms and confirmatory electrodiagnostic studies should be started on conversative management, i.e. rest, splinting, education, and occupational or ergonomic interventions. Although considered to be a conservative treatment option, local corticosteroid injection should be considered secondarily to the aforementioned.
Patients are considered to be refractory to conservative treatment if there is no symptom or functional ability improvement following a one month trial of splinting and/or after receiving two or more corticosteroid injections in a twelve month period1. In this situation the patient should be referred for surgical release.
If the patient is diagnosed with severe CTS based on electrodiagnostic studies or experiences persistent sleep disturbance or interference with work or lifestyle activities then surgical release may be considered as first line treatment.
NB: Patients with pregnancy related CTS should be managed with rest and splints regardless of symptom severity since symptoms usually resolve post-partum.
Treatment Summary
|
Treatment |
Effectiveness |
Advantages |
Disadvantages |
Complications |
Use |
|
Splinting |
Possibly effective treatment; No difference in effectiveness between netural and 20 degrees of extension; No difference in effectiveness between nighttime and continuous use |
Harmful effects are very rare and resolve with splint discontinuation |
Poor compliance; Continuous use may be of no added benefit and restricts the patient in their day to day activities; Less effective than steroid injections and surgery |
Wrist-splint-related paraesthesias; Resolve upon discontinuation of splint; Usually because splints are too tight and/or ill fitting |
1st line for mild CTS (clinical diagnosis without EMG) and for mild to moderate CTS based on EMG |
|
Local Corticosteroid Injection |
Effective symptom relief; Most effective non-surgical treatment; May be equally effective as surgery in terms of improving hand function |
Some patients may not progress to surgery |
Temporary relief; Unknown which steroid, dose, volume, or technique is most effective |
Tendon rupture; Intraneural injection can cause acute severe neuropathy |
Usually 2nd line for mild to moderate CTS based on EMG; Useful for flare-ups and cases where surgery is delayed |
|
Oral Corticosteroid |
Effective short- term symptom relief; Less effective than steroid injection |
Some patients may not progress to surgery |
Many adverse effects |
Osteoporosis, adrenal insufficiency, elevated blood glucose levels (DM), dyslipidemias, HTN, insomnia, mood swings, headaches, nausea |
Long-term use not recommended |
|
Nerve and tendon gliding exercises |
Possibly effective treatment; May improve grip strength but does not improve prehension, symptoms or NCS |
Noninvasive |
Reduced surgical rates may be the result of confounders; Involves some stretching of the median nerve which may exacerbate symptoms |
No harmful effects have been documented |
Carefully consider use as an adjunct |
|
Therapeutic ultrasound |
Possibly effective treatment; More evidence is needed |
Noninvasive |
Many different types, intensities and durations which makes evaluation difficult |
No harmful effects have been documented |
Carefully consider use as an adjunct |
|
Massage therapy |
Potentially ineffective; No reduction in symptom measures |
Potential break-down of scar tissue |
More investigation is required |
Unknown |
Carefully consider use as an adjunct |
|
Acupuncture |
Unknown effectiveness |
Unknown |
More investigation is required |
Unknown |
Carefully consider use as an adjunct |
|
NSAIDs |
Potentially ineffective; No reduction in symptom measures |
Decreased associated joint pain |
Bleeding complications |
Adverse GI events |
May be helpful for patients who have significant inflammation or arthritis |
|
Diuretics |
Potentially ineffective; May be effective in patient with fluid retention |
Unknown |
Electrolyte imbalances |
Elevated serum uric acid levels; Hypokalemia; Increased blood glucose levels |
Carefully consider use as an adjunct |
|
Pyridoxine (Vitamin B12) |
Potentially ineffective; No reduction in symptom measures |
Reduced finger swelling |
Unknown |
Excess pyridoxine may lead to a sensory neuropathy (paraesthesia, unsteady gait) |
Carfeully consider use as an adjunct |
|
Surgery |
Effective treatment in terms of improvement in hand symptoms and function |
See below |
Unknown optimal timing of when to operate |
See below |
1st line for severe CTS based on EMG; 3rd line for failed conservative management; Patients with predisposing conditions may benefit from more aggressive management with early surgical referral |
|
Endoscopic Carpal Tunnel Release |
Equally effective as OCTR |
Faster return to work than OCTR |
More resource intensive and higher surgical skill needed than OCTR; More transient nerve problems |
Neurapraxia, numbness, paraesthesias |
|
|
Open Carpal Tunnel Release |
Equally effective as ECTR |
Less resource intensive than ECTR |
Longer return to work and resumption of ADLs than ECTR; More wound problems |
Infection, hypertrophic scarring, scar tenderness |
DM: Diabetes Mellitus, HTN: Hypertension, GI: gastrointestinal, ADL: Activities of daily living, OCTR: Open carpal tunnel release, ECTR: Endoscopic carpal tunnel release.
1Marshall SC, Tardif G, Ashworth NL. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database of Systematic Reviews 2007, 2:CD001554.