Carpal tunnel syndrome (CTS) is caused by the tendons in the wrist getting too tight and thus putting pressure on the nerves that run beneath them. The symptoms can include:
- pain in fingers, hand or arm,
- numb hands,
- tingling or ‘pins and needles’,
- a weak thumb or difficulty gripping.
These symptoms often start slowly and they can come and go but often get worse over time. They are usually worse at night and may keep patients from having a good night’s sleep.
The treatments advocated for CTS include painkillers, splints and just about every alternative therapy one can think of, particularly acupuncture. Acupuncture may be popular, but does it work?
This new Cochrane review was aimed at assessing the evidence for acupuncture and similar treatments for CTS. It included 12 studies with 869 participants. Ten studies reported the primary outcome of overall clinical improvement at short‐term follow‐up (3 months or less) after randomisation. Most studies could not be combined in a meta‐analysis due to heterogeneity, and all had an unclear or high overall risk of bias. Only 7 studies provided information on adverse events.
The authors (two of them are from my former Exeter team) found that, in comparison with placebo or sham-treatments, acupuncture and laser acupuncture have little or no effect in the short term on symptoms of CTS. It is uncertain whether acupuncture and related interventions are more or less effective in relieving symptoms of CTS than corticosteroid nerve blocks, oral corticosteroids, vitamin B12, ibuprofen, splints, or when added to NSAIDs plus vitamins, as the certainty of any conclusions from the evidence is low or very low and most evidence is short term. The included studies covered diverse interventions, had diverse designs, limited ethnic diversity, and clinical heterogeneity.
The authors concluded that high‐quality randomised controlled trials (RCTs) are necessary to rigorously assess the effects of acupuncture and related interventions upon symptoms of CTS. Based on moderate to very‐low certainty evidence, acupuncture was associated with no serious adverse events, or reported discomfort, pain, local paraesthesia and temporary skin bruises, but not all studies provided adverse event data.
This last point is one that I made very often: most trials of acupuncture fail to report adverse effects. This is doubtlessly unethical (it gives a false-positive overall impression about acupuncture’s safety). And what can you do with studies that are unethical? My answer is simple: bin them!
Most of the trials were of poor or very poor quality. Such studies tend to generate false-positive results. And what can you do with studies that are flimsy and misleading? My answer is simple: bin them!
So, what can we do with acupuncture trials of CTS? … I let you decide.
But binning the evidence offers little help to patients who suffer from chronic, progressive CTS. What can those patients do? Go and see a surgeon! (S)he will cure you with a relatively simply and safe operation; in all likelihood, you will never look back at dubious treatments.
22 Responses to Acupuncture for carpal tunnel syndrome – bin the studies and consult a surgeon!
Leave a Reply to jrkrideau Cancel reply
This site uses Akismet to reduce spam. Learn how your comment data is processed.
Before the surgery, wrist mobilisation/manipulation of the wrist is a much more conservative approach that, if effective will be efficacious in a very short period of time. Let us not forget that these symptoms may also be a sign of cervical involvement that responds well to cervical manual therapy and traction.
“if effective will be efficacious”
one of the most nonsensical statements for a while.
“these symptoms may also be a sign of cervical involvement that responds well to cervical manual therapy and traction.”
well, then it would not be CTS, would it? do chiros not make proper diagnoses?
I would agree that it is important to consider cervical root compression, as mild compression of a nerve at two points along its length can lead to more severe symptoms. I would also want to check for other underlying conditions associated with carpal tunnel syndrome such as thyroid dysfunction, rheumatoid disease, fluid retention from all causes, diabetes, pregnancy and indeed occupational factors that can be addressed.
Endorsed 100%
Proper workup is of course necessary and many surgeons always do nerve conduction tests before surgery even if clinical examination is usually enough to safely distinguish a carpal tunnel compression from cervical causes. Aggravating factors that increase the pressure by general fluid retention may even include pregnancy and should of course be considered. As Julian points out, occupational factors like vibration should also be addressed.
Surgery is not the first thing one should decide in mild cases but when signs of impending nerve damage set in it should be considered. UpToDate has an elaborate, well researched section on this problem, available for physicians on subscription and there is also an informative patient information section: https://www.uptodate.com/contents/carpal-tunnel-syndrome-the-basics
Hmmm…EE…”do chiros not make proper diagnoses?”
Carpal tunnel syndrome (CTS) screening is problematic and often inaccurate. Surgical treatment for CTS, involving open-hand or endoscopic ligament releases, accounts for 11% of all surgeries performed. Of these surgeries, about 50% fail. We compared the sensitivity and specificity of CTS screening tests. Using multiple screening tests is believed to increase accuracy, but the results showed specificity decreases to 48% or less. Most misdiagnoses were false negatives, suggesting that many surgical treatments were unnecessary. This systematic misclassification based on imprecise screening tests is also an error of omission when physicians have only these tests to use. A new screening method and test are considered.
https://journals.lww.com/jcejournal/Abstract/2009/04000/Misdiagnosis_of_Carpal_Tunnel_Syndrome__A.23.aspx
DC,
I have followed your link to a paper published in the Journal of Clinical Engineering by two engineers and a non-medically-qualified researcher at the Community Medical Foundation in Texas. I can read the abstract, which you quoted, but not the rest of the article, which is behind a paywall.
The abstract makes very little sense to me. I am not aware of any screening programme for carpal tunnel syndrome, and it doesn’t seem to me the sort of condition which particularly lends itself to screening (unlike, for instance, cervical cancer, where screening has saved a great many lives worldwide). The only reason that I can think of for screening for it might be in occupational health, where early diagnosis could lead to a change in working conditions to prevent progression, and might also reduce the risk of a lawsuit in the notoriously litigious US.
I am rather surprised at the figure of 11% of all surgeries performed (or operations, as they are called in most of the English-speaking world), but the authors don’t state what population these figures are derived from. Perhaps a hand clinic?
“Using multiple screening tests is believed to increase accuracy, but the results showed specificity decreases to 48% or less. Most misdiagnoses were false negatives”
One of the authors has a PhD in epidemiology, so he should know that screening tests are never intended to be used to make a diagnosis. Their function is to identify a high-risk sub-population who can then be fed into the diagnostic process.
“Most misdiagnoses were false negatives, suggesting that many surgical treatments were unnecessary”
What???
If a screening test has a lot of false negatives, then that means that it isn’t a very good test as it will fail to identify many of the cases. It does not suggest anything about the necessity of surgical treatments. The referees should have picked up such a basic error, and so should the editors of the journal.
“systematic misclassification based on imprecise screening tests is also an error of omission when physicians have only these tests to use”
They don’t. They also have their clinical skills, and access to diagnosistic tests as Bjorn has described above.
I don’t know what this nonsense of a paper is about, nor what your point is in referencing it. Would you care to elucidate further?
@DC
You win this years grand prize for creative cherry picking!
How you managed to find this paper and believe you could get away with presenting it here, is beyond me. How it came to be written and published is an even bigger mystery.
Screening is not needed in CTS, the patients come asking for help. Screening is an instrument to find symptomless patients, before the problem becomes clinically evident. At such a stage, treatment is not necessary. Of course preemptive measures may be indicated but I doubt that screening for subclinical cases of carpal tunnel compression could ever be cost-effective.
Finding out if the cause of symptoms is carpal tunnel compression is rather easy. simple clinical tests are described here: https://www.webmd.com/pain-management/carpal-tunnel/carpal-tunnel-diagnosis#1
Many surgeons and rheumatologists and others have ultrasound equipment in their office nowadays and nerve conduction tests are easy and cheap to rule out cervical or other cause. As I said before, many surgeons do them even if the clinical tests are unequivocal, just to make sure and to cover their a$$ in case the surgery should not give satisfactory results.
The success rate of surgery for carpal tunnel syndrome is in competent hands over 90%, long term. See e.g. this:
https://online.boneandjoint.org.uk/doi/abs/10.1302/0301-620X.99B10.BJJ-2016-0587.R2
Here’s an interesting overview by an organisation usually held in high respect: http://www.evidentlycochrane.net/carpal-tunnel-syndrome/
Björn…I thought cherry picking papers was the norm here. But thanks for the prize.
Another view perhaps (2008)
“Although we make every effort to find studies of the highest quality, such evidence is not readily available for carpal tunnel syndrome treatment at this time. This guideline has been hindered by a relative lack of power in the studies even though these studies were of Level I and II evidence. The recommendations of this guideline therefore depend to some degree on lesser evidence, including expert opinion.
To achieve a high-quality literature base, academic authors and scientists should invest their time and effort in studies designed to avoid bias (e.g., blinded and properly randomized controlled trials of sufficient power to address the outcome of interest). Future studies should, from the onset, be based on improved study design that includes a priori power calculations. Risk stratification studies are also needed to detect when antibiotics might be justified on the basis of co-morbidities and co-interventions.”
Recommendations
The American Academy of Orthopaedic Surgeons
@DC
What are you getting at? This text you cut-and-pasted is TEN years old. That is a very long time in modern medical science. Progress is fast. The long term study I linked is from last year. Of course rigorous scientific efforts need to be encouraged, always. Why dont you look for recent work like the one I linked, there is more, and tell us what you think of it. The one I linked has many aspects that can be questioned. But the results are brilliant. Do you think they can be trusted? Do other recent papers support their findings or raise suspicion that their results might be doubtful? Why don´t you use the holidays to do a review of your own and tell us what recent evidence says?
@fake “Dr”: IF by “responds well” you mean the patient pays for you to ply them with theatrics and dogma while their condition goes away on its own….then yes they work really well.
As everything works “really well” in the imaginings of a healthcare “doctor” who has never delivered a baby, stitched a wound, prescribed medicine, saved a life or did an internship in a real hospital with real sick people…. Where what “really works” means more than just a monetary-exchange.
So, what can we do with acupuncture trials of CTS?
If printed, the studies can be shredded and used as packing material or possibly used as a mulch?
Let’s make proper use of these studies.
Electroacupuncture for CTS which gives a positive objective outcome
https://academic.oup.com/brain/article/140/4/914/3058778
one small trial which arguably used electrotherapy.
I am not convinced.
and in any case, this trial is included in the review.
When are people going to understand that electrostimulation using needle electrodes is NOT ACUPUNCTURE!
This bloated paper seems weird. They confuse terms back and forth and go on about phenomena like neuroplasticity and do brain imaging studies in a seemingly unfocused manner when the problem is that of a simple peripheral nerve entrapment that is easy to manage using well tried and tested methods.
As the professor points out, a good surgeon fixes this in minutes with a relatively safe procedure.
For mild cases and those who are afraid of surgery, wrist immobilisation (Mr. Epstein, note that this means the opposite of mobilisation and manipulation) is effective and steroids are sometimes added.
A complicated method of mobilisation of the wrist bones has been proposed by occupational therapists but is not supported by good evidence and is anatomically doubtful. The temporary benefit may be simply.
due to a massaging effect mobilising some oedema around the nerve. This does not constitute significant relief or cure.
I dont think its included in the Cochrane review you mention…..its a newer study
@Yak sie
Don’t think, read and study!
If you had read both the paper and the Cochrane report you would have discovered that the paper was published in april 2017 and the search for studies was done in november 2017.
Your thinking is wrong.
Thanks for your comments. Please can you help.
Would you be able to offer an explanation of why the verum electrostimulation/electrotherapy in this trial was beneficial in the nerve conduction measurements on follow up of the verum group(s) ?
Im intrigued !
if you search for ‘electrotherapy’, you might find the answer yourself
I have had a look at electrotherapy but would still be greatly interested in your opinion if you think this is, or is an effective way of treating true CTS, especially based on objective results being favourable in this trial. It could be very beneficial to patients if conservative options and surgery have failed after correct and orthodox diagnosis.
I did look on the trials included and excluded on the review and this trial seems to be missed.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011215.pub2/references#CD011215-sec2-0028
@Yak sie
The study that comes up with your link is not a study on acupuncture but on low-level laser light irradiation in the vicinity of the median nerve proximal to the carpal tunnel. How that might help is unclear, to put it mildly. It seems to be ongoing and is grouped among studies awaiting assessment so I don’t really understand why you think it was missed?
From this registration it seems to have been ongoing from 2010 but not yet published. Might that possibly be because it did not show any effect and “negative results”- publications are not popular in the part of the world where it is conducted??