Rehabilitation following carpal tunnel release New search for studies and content updated (no change to conclusions)

Abstract

Abstract Background

Various rehabilitation treatments may be offered following carpal tunnel syndrome (CTS) surgery. The effectiveness of these interventions remains unclear. This is the first update of a review first published in 2013.

Objectives

To review the effectiveness and safety of rehabilitation interventions following CTS surgery compared with no treatment, placebo, or another intervention.

Search methods

On 29 September 2015, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL Plus, AMED, LILACS, and PsycINFO. We also searched PEDro (3 December 2015) and clinical trials registers (3 December 2015).

Selection criteria

Randomised or quasi‐randomised clinical trials that compared any postoperative rehabilitation intervention with either no intervention, placebo, or another postoperative rehabilitation intervention in individuals who had undergone CTS surgery.

Data collection and analysis

Two review authors independently selected trials for inclusion, extracted data, assessed risk of bias, and assessed the quality of the body of evidence for primary outcomes using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach according to standard Cochrane methodology.

Main results

In this review we included 22 trials with a total of 1521 participants. Two of the trials were newly identified at this update. We studied different rehabilitation treatments including immobilisation using a wrist orthosis, dressings, exercise, controlled cold therapy, ice therapy, multi‐modal hand rehabilitation, laser therapy, electrical modalities, scar desensitisation, and arnica. Three trials compared a rehabilitation treatment to a placebo, four compared rehabilitation to a no treatment control, three compared rehabilitation to standard care, and 15 compared various rehabilitation treatments to one another.

Overall, the included studies were very low in quality. Thirteen trials explicitly reported random sequence generation; of these, five adequately concealed the allocation sequence. Four trials achieved blinding of both participants and outcome assessors. Five were at high risk of bias from incompleteness of outcome data at one or more time intervals, and eight had high risk of selective reporting bias.

These trials were heterogeneous in terms of treatments provided, duration of interventions, the nature and timing of outcomes measured, and setting. Therefore, we were not able to pool results across trials.

Four trials reported our primary outcome, change in self reported functional ability at three months or more. Of these, three trials provided sufficient outcome data for inclusion in this review. One small high‐quality trial studied a desensitisation programme compared with standard treatment and revealed no statistically significant functional benefit based on the Boston Carpal Tunnel Questionnaire (BCTQ) (mean difference (MD) ‐0.03, 95% confidence interval (CI) ‐0.39 to 0.33). One low‐quality trial assessed participants six months post surgery using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and found no significant difference between a no formal therapy group and a group given a two‐week course of multi‐modal therapy commenced at five to seven days post surgery (MD 1.00, 95% CI ‐4.44 to 6.44). One very low‐quality quasi‐randomised trial found no statistically significant difference in function on the BCTQ at three months post surgery with early immobilisation (plaster wrist orthosis worn until suture removal) compared with a splint and late mobilisation (MD 0.39, 95% CI ‐0.45 to 1.23).

Differences between treatments for secondary outcome measures (change in self reported functional ability measured at less than three months; change in CTS symptoms; change in CTS‐related impairment measures; presence of iatrogenic symptoms from surgery; return to work or occupation; and change in neurophysiological parameters) were generally small and not statistically significant. Few studies reported adverse events.

Authors' conclusions

There is limited and, in general, low quality evidence for the benefit of the reviewed interventions. People who have undergone CTS surgery should be informed about the limited evidence of effectiveness of postoperative rehabilitation interventions. Until researchers provide results of more high‐quality trials that assess the effectiveness and safety of various rehabilitation treatments, the decision to provide rehabilitation following CTS surgery should be based on the clinician's expertise, the patient's preferences and the context of the rehabilitation environment. It is important for researchers to identify patients who respond to a particular treatment and those who do not, and to undertake high‐quality studies that evaluate the severity of iatrogenic symptoms from surgery, measure function and return‐to‐work rates, and control for confounding variables.

Author(s)

Susan Peters, Matthew J Page, Michel W Coppieters, Mark Ross, Venerina Johnston

Abstract

Plain language summary

Rehabilitation following carpal tunnel release

Review question

Are rehabilitation interventions after surgery for carpal tunnel syndrome effective and safe?

Background

Carpal tunnel syndrome (CTS) is a condition in which a nerve that runs through a bony and fibrous tunnel in the wrist is compressed. This leads to pain, numbness and tingling in the hand, sometimes extending into the forearm. At advanced stages, some people with CTS have weakness and muscle wasting in the hand. CTS is more common in women and individuals with certain risk factors, such as diabetes, obesity, arthritis, older age, working in certain occupations, and previous wrist fracture. Many people undergo surgery to reduce pressure on the nerve, to lessen pain, and improve sensation and hand function. Sometimes individuals receive rehabilitation following CTS surgery. Rehabilitation treatments are believed to speed up recovery and manage pain or symptoms from the surgery itself. This is the first update of a review first published in 2013.

Study characteristics

On 29 September 2015, we searched for all relevant clinical trials in which a rehabilitation treatment was compared with another rehabilitation treatment, no treatment or placebo (sham treatment). We found 22 trials with a total of 1521 participants that assessed the benefits and harms of different rehabilitation treatments following CTS surgery. Two of the trials were newly identified at this update.

Key results and quality of the evidence

Based on these studies, we found limited and low quality evidence for the benefit of the reviewed treatments, including immobilisation with a wrist orthosis (splint), use of dressings post surgery, exercise, cold and ice therapy, different types of hand rehabilitation provided in combination, laser therapy, electrical treatments, scar desensitisation, and arnica. Few studies reported on the safety of these treatments.

More research is needed to investigate the effectiveness and safety of the various types of rehabilitation treatment available for people following CTS surgery.

The evidence is up to date to September 2015.

Author(s)

Susan Peters, Matthew J Page, Michel W Coppieters, Mark Ross, Venerina Johnston

Reviewer's Conclusions

Authors' conclusions

Implications for practice

Limited and very low‐quality evidence is available for rehabilitation treatments following carpal tunnel release (CTR). People who have undergone CTR require sufficient information to make an informed decision about recommended rehabilitation treatments. They need to be informed of the limited evidence of effectiveness and safety of any interventions recommended by the treatment provider. Factors to be considered before treatment providers and those who refer patients for treatment recommend a rehabilitation following surgery for carpal tunnel syndrome (CTS) are the environmental context, the nature of the intervention, and the patient's preference. Benefits of rehabilitation treatments in the short term compared with the long term have not been adequately evaluated.

Implications for research

Carpal tunnel release surgery is generally successful in reducing symptoms of CTS with few reported adverse events (Vasiliadis 2013; Verdugo 2008). Therefore, studies with large samples and the power to detect statistically significant differences between groups are needed to determine the effects of interventions in improving postoperative outcomes, including function and return to work. The high success rate of surgery may contribute to the lack of high‐quality studies. Second, a wide variety of poor outcomes are possible after surgery, and it can be difficult to design a study to examine multiple outcomes while controlling for various confounding variables. Poor outcomes can result from failure to relieve preexisting symptoms or iatrogenic complications from the surgery itself (e.g. scar pain, hypersensitivity, and reduced grip strength). However, for patients who have persistent symptoms or iatrogenic effects resulting from CTR, research into effects of various rehabilitation modalities remains relevant and necessary.

Therefore, additional high‐quality randomised controlled trials are needed to assess the effectiveness and safety of rehabilitation treatments delivered after CTR. Researchers must consider various issues when designing a study (Peters 2014). Trials should attempt to blind participants and outcome assessors when possible. Trial authors should clearly report demographic details and rehabilitation setting information, so that results can be interpreted and applied to similar populations and settings. In addition, data on adverse effects of the rehabilitation intervention rather than iatrogenic effects of the surgery should be recorded. If participants with bilateral CTS are included in the study, trialists should use appropriate methods and should clearly report how bilateral cases were handled in their statistical analysis to prevent a unit of analysis error. Study authors should place trial information on appropriate clinical trials registers to ensure transparent reporting of methods planned for their study. Moreover, trialists should be careful to include in the study report means and appropriate measures of variability for all outcomes prespecified in their methods, thereby avoiding selective reporting bias. The nature of these interventions and the results reported by trials included in this review show that benefit may be observed for early return to function and return to work that is not observed at three months or later. However, longer‐term effectiveness should not be ignored. Assessment of longer‐term benefit after cessation of the intervention should be incorporated in future research. Researchers should focus on postoperative care regimens that have been designed to reduce the symptoms of CTS. They need to measure the severity and type of CTS symptoms preoperatively and should stratify the patient population accordingly. Additionally, consistent reporting of outcomes (common instruments and timing of outcome assessments) will allow for meta‐analysis of similar outcomes in future reviews. The only consistent effects of treatment involved CTS symptom scores; therefore, these outcomes might be useful to include in future studies. Finally, many commonly used rehabilitation treatments have not yet been evaluated for their effectiveness or safety, and these therapies should be included in future trials.

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