Electrophysiological responsiveness and clinical outcomes of local corticosteroid injection in the treatment of carpal tunnel syndrome / Responsividade eletrofisiológica e desfechos clínicos da injeção local de corticosteroide no tratamento da síndrome do túnel do carpo

ABSTRACT Carpal tunnel syndrome (CTS) is the most common mononeuropathy caused by entrapment of the median nerve at the wrist. Common treatment options for CTS include oral analgesics, splinting, hand therapy, local injections with steroids or surgery. Objective: The aim of the present study was to assess the short-term clinical and electrophysiological outcomes of local corticosteroid injection (LCI) in patients with symptomatic CTS. Methods: Electrophysiological parameters were evaluated before and three months after LCI. Moreover, the Numeric Rating Scale (NRS), the Boston Symptom Severity Scale (SSS) and the Functional Status Scale (FSS) were administered before and after the injection. A mixture of 1 mL (40 mg) of methylprednisolone and 1 mL of 0.5% bupivacaine were injected blindly on the volar side of the forearm between the tendons of the radial carpal flexor muscle and long palmar muscle. Results: A total of 25 patients (45 hands) were enrolled in the study. Twenty women and five men with a mean age of 49.28 ± 11.37 years were included. A statistically significant difference was noted for improvement of sensory conduction velocities, sensory peak latency, and motor distal latency (p = 0.001) after LCI. A significant difference was recorded between pre- and post-injection for NRS, SSS and FSS scores (p = 0.000). Conclusion: Local corticosteroid injection for CTS provides a short-term improvement in neurophysiological and clinical outcomes such as pain intensity, symptom severity and functional ability.

RESUMO A síndrome do túnel do carpo (STC) é a mononeuropatia mais comum causada pelo aprisionamento do nervo mediano no punho. Opções comuns de tratamento para STC incluem analgésicos orais, splinting, terapia de mão, injeções locais com esteroides ou cirurgia. Objetivo: O objetivo do presente estudo foi avaliar os resultados clínicos e eletrofisiológicos de curto prazo da injeção de corticosteroide local (ICL) em pacientes com STC sintomática. Métodos: Os parâmetros eletrofisiológicos foram avaliados antes e três meses após a ICL. Além disso, a Escala Numérica de Avaliação (NRS), a Escala de Gravidade de Sintomas de Boston (BSS) e a Escala de Status Funcional (FSS) foram administradas antes e após a injeção. Uma mistura de 1 ml (40 mg) de metilprednisolona e 1 ml de bupivacaína a 0,5% foi injetada cegamente no lado do antebraço entre os tendões do músculo flexor radial do carpo e o músculo palmar longo. Resultados: Um total de 25 pacientes (45 mãos) foi incluído no estudo. Vinte mulheres e cinco homens com idade média de 49,28 ± 11,37 anos foram incluídos. Foi observada diferença estatisticamente significante para melhora das velocidades de condução sensitiva, latência de pico sensorial, latência motora distal (p = 0,001) após a ICL. Uma diferença significativa foi registrada entre pré e pós-injeção para os escores NRS, BSS e FSS (p = 0,000). Conclusão: A ICL para STC fornece uma melhoria a curto prazo em resultados neurofisiológicos e clínicos, tais como intensidade da dor, gravidade dos sintomas e capacidade funcional.

Cross-Cultural Adaptation of the Korean Version of the Boston Carpal Tunnel Questionnaire: Its Clinical Evaluation in Patients with Carpal Tunnel Syndrome Following Local Corticosteroid Injection

The aim of this study was to assess and validate the Korean version of the Boston Carpal Tunnel Questionnaire (K-BCTQ) in patients with carpal tunnel syndrome (CTS). After translation and cultural adaptation of the BCTQ to a Korean version, the K-BCTQ was administered to 54 patients with CTS; it was administered again after 2 weeks to assess reliability. Additionally, we administered K-DASH and EQ-5D to assess construct-validity. In a prospective study of responsiveness to clinical change, 29 of 54 patients were treated by ultrasonography-guided local corticosteroid injection therapy. The internal consistency of the K-BCTQ was high (Cronbach's alpha: 0.915) and the intra-class correlation coefficients were 0.931 for the symptom severity scale (P<0.001) and 0.844 for the functional severity scale (P<0.001). The construct-validity between the symptom severity scale and the K-DASH, and between the functional severity scale and the K-DASH were significantly correlated (both P<0.001). Clinical improvement was noted in 29 patients with injection therapy. The effect size of symptom severity was 0.67, and that of functional severity was 0.58. In conclusion, the K-BCTQ shows good reliability, construct-validity, and acceptable responsiveness after local corticosteroid injection therapy (Clinical trial number, KCT0000050).

Study of long term effects of laser therapy versus local corticosteroid injection in patients with carpal tunnel syndrome

Carpal Tunnel Syndrome [CTS] is the most common compressive neuropathy. Several surgical and nonsurgical treatments have been proposed for this syndrome, but there is no consensus regarding the prioritization of the suggested nonsurgical treatments. The goal of this study was to compare the long term effects of laser therapy versus local corticosteroid injection in the treatment of CTS. During this single-blind randomized clinical trial, 65 hands with mild or moderate CTS were divided randomly into two groups. One group received local corticosteroid injection [Hydrocortisone 50 mg] and the other received low level laser therapy [20J/cm in 11 seconds/session for each of 5 points, 775nm, 10 sessions and 3sessions/week]. Furthermore, wrist splints with extension degree of 0 [neutral position] were prescribed simultaneously for 6 weeks in each group. Pain severity and electrodiagnostic measurements were compared from before to 10 months after completing each treatment. Data were analyzed with SPSS 11.5 software and parametric tests. Generally, the mean age of patients was 43.9 years, duration of pain was 7.4 months, male to female ratio was 1:3, pain severity using Visual Analogue Scale [VAS] was 6.1 cm, and functional status measure was 15.5. The severity of the disease based on electrodiagnostic studies was 43.2% mild [41.2% in injection group and 45.2% in laser therapy group] and 56.8% moderate. The electrodiagnostic characteristics of the median nerve prior to treatment were included mean sensory peak latency of 4.3ms, mean sensory amplitude of 23.5mv, mean motor onset latency of 4.3ms and mean motor amplitude of 4.6mv. There was no meaningful difference between two groups regarding the demographic characteristics and electrodiagnostic measures [p>0.05]. Ten months after treatments, the mean of pain severity was decreased 1.9cm in injection group and 1.7cm in laser therapy group, the mean of median sensory peak latencies was decreased 0.4ms in injection group and 0.25ms in laser therapy group and the mean of motor onset latencies was decreased 0.15ms in both groups, with no significant difference between the observed treatments variables [P>0.05]. The severity of disease based on electrodiagnostic studies became 32.4% normal, 23.5% mild, 41.2% moderate and 2.9% severe in the injection group and 38.7% normal, 22.6% mild, 35.5% moderate and 3.2% severe in the laser therapy group. There was no meaningful difference between two groups regarding the changes in the pain severity, functional status and electrodiagnostic measures. Low level laser therapy can be as effective as local injection in reducing pain and severity of disease [based on electrodiagnostic medicine classification] in patients with mild and moderate CTS even in long term [after 10 months]

Citocinas pró-inflamatórias em pacientes com dor neuropática submetidos a tratamento com Tramadol / Proinflammatory cytokines in patients with neuropathic pain treated with Tramadol / Interleucinas proinflamatorias en pacientes con dolor neuropático sometidos a tratamiento con Tramadol

JUSTIFICATIVA E OBJETIVOS: As citocinas pró-inflamatórias têm função importante na fisiopatologia das síndromes dolorosas neuropáticas. O objetivo desse estudo foi avaliar os níveis plasmáticos de citocinas pró-inflamatórias antes e após o tratamentocom tramadol em pacientes com hérnia discal e síndrome do túnel do carpo e compará-los com indivíduos normais.MÉTODO: Investigou-se 38 pacientes com dor neuropática por hérnia discal ou síndrome do túnel do carpo. Todos os pacientes foram tratados com tramadol de liberação controlada (100 mg em 12h) durante 10 dias. Realizaram-se coletas de sangue venoso (5 mL), no período matutino, antes do tratamento e no 11º dia e as amostras foram armazenadas até análise (-70ºC). Foram utilizados testes enzimáticos ELISA para dosagem de citocinas plasmáticas (TNF-α, IL-1, IL-6) e receptores sTNF-R1, (R & D Systems). Realizou-se dosagem de citocinas em soro de 10 voluntários sadios. RESULTADOS: A concentração de TNF-α antes (5,8 ± 2,8 pg.mL-1) foi significativamente maior que após o tramadol (4,8 ± 2,1 pg.mL-1; p = 0,04, Teste Mann-Whitney). Não houve diferença significativa de IL-1β, IL-6 e sTNF-R1 antes e após o tratamento. As concentrações plasmáticas de TNF-α (sadios: 1,4 ± 0,5; pacientes com dor: 5,8 ± 2,8 pg.mL-1; p = 0.01) e IL-6 (sadios: 1,2 ± 0,8; pacientes com dor: 3,5 ± 2,6 pg.mL-1; p = 0,01) foram significativamente maiores nos pacientes com dor neuropática que nos voluntários, Teste de Mann-Whitney. CONCLUSÕES: Nos pacientes com hérnia discal e síndrome do túnel do carpo as concentrações plasmáticas de TNF-α e IL-6 foram maiores que em voluntários sadios, não havendo diferença das concentrações de sTNF-R e IL-1β. Houve redução da concentraçãoplasmática de TNF-α após tratamento com tramadol (100 mg em 12h), mas não de IL-6, sTNF-R e IL-1β.

BACKGROUND AND METHODS: Proinflammatory cytokines play an important role in the pathophysiology of neuropathic pain syndromes. The objective of this study was to evaluate plasma levels of proinflammatory cytokines before and after treatment with tramadol in patients with herniated intervertebral disks and carpal tunnel syndrome, and to compare them with normal individuals. METHODS: Thirty-eight patients with neuropathic pain secondary to herniated intervertebral disks or carpal tunnel syndrome participated in this study. All patients were treated with controlled release tramadol (100 mg every 12 hours) for 10 days. Venous blood (5 mL) was collected in the morning, before treatment and on the 11th day, and stored (-70º C) until analysis. ELISA was used to determine the plasma levels of cytokines (TNF-α, IL-1, IL-6) andreceptors sTNF-R1 (R & D Systems). Plasma levels of cytokines of 10 healthy volunteers were also determined. RESULTS: The concentration of TNF-α before (5.8 ± 2.8 pg.mL-1) was significantly higher than after treatment with tramadol (4.8 ± 2.1 pg.mL-1; p = 0.04, Mann-Whitney test). The levels of IL-1β, IL-6, and sTNF-R1 before and after treatment with tramadol showed nosignificant differences. Plasma levels of TNF-α (healthy individuals: 1.4 ± 0.5; pain patients: 5.8 ± 2.8 pg.mL-1; p = 0.01) and IL-6 (healthy individuals: 1.2 ± 0.8; pain patients: 3.5 ± 2.6 pg.mL-1; p = 0.01) were significantly higher in patients with neuropathic pain, Mann-Whitney Test. CONCLUSIONS: In patients with herniated intervertebral disks and carpal tunnel syndrome, plasma levels of TNF-α and IL-6 werehigher than in healthy volunteers, while differences in the concentrations of sTNF-R and IL-1β were not observed. Plasma levels of TNF-α, but not of IL-6, sTNF-R, and IL-1β, decreased after treatment with tramadol (100 mg every 12 hours).

JUSTIFICATIVA Y OBJETIVOS: Las interleucinas proinflamatorias tienen una función importante en la fisiopatología de los síndromes dolorosos neuropáticos. El objetivo de este estudio, fue evaluar los niveles plasmáticos de interleucinas proinflamatorias antes y después del tratamiento con tramadol en pacientes con hernia de disco y síndromedel túnel del carpo, y compararlos con individuos normales. MÉTODO: Se investigaron 38 pacientes con dolor neuropático por hernia de disco o síndrome del túnel del carpo. Todos los pacientes fueron tratados con tramadol de liberación controlada (100 mg en 12h) durante 10 días. Se realizaron muestras de sangre venosa (5 mL), por la mañana, antes del tratamiento y en el 11º día, y las mismas se almacenaron para ser analizadas (-70ºC). Se utilizaron test enzimáticos ELISA para la dosificación de las interleucinas plasmáticas (TNF-α, IL-1, IL-6) y receptores sTNFR1, (R & D Systems). Se realizó la dosificación de interleucinasen suero de 10 voluntarios sanos. RESULTADOS: La concentración de TNF-α antes (5,8 ± 2,8 pg.mL-1) fue significativamente mayor que después del tramadol (4,8 ± 2,1 pg.mL-1; p = 0,04, Test de Mann-Whitney). No hubo diferencia significativa de IL-1β, IL-6 y sTNF-R1 antes y después del tratamiento. Las concentraciones plasmáticas de TNF-α (sanos: 1,4 ± 0,5; pacientes con dolor: 5,8 ± 2,8 pg.mL-1; p = 0.01) y IL-6 (sanos: 1,2 ± 0,8; pacientes con dolor: 3.5 ± 2,6 pg.mL-1; p = 0,01) fueron significativamente mayores en los pacientes con dolor neuropático que en los voluntarios, test de Mann-Whitney. CONCLUSIONES: En los pacientes con hernia discal y síndrome del túnel del carpo, las concentraciones plasmáticas de TNF-α yIL-6, fueron más elevadas que en los voluntarios sanos, no habiendo ninguna diferencia en las concentraciones de sTNF-R y IL-1β...

outcome of surgical decompression for carpal tunnel syndrome yields better functional results than conservative management and steroid injection

Surgery for carpal tunnel syndrome is reserved for severe cases or for those having intractable and longstanding symptoms. Non-surgical treatment modalities include hand splinting, ultrasound, oral non-steroidal anti-inflammatory drugs, local steroid injection, and some physiotherapeutic measures. The objective of this study is to evaluate the effectiveness of non-surgical treatment versus standard surgery in improving clinical outcome. Twenty seven patients with carpal tunnel syndrome were categorized into three groups [12, 9 and 6 patients respectively]. Group I received conservative management, and intra-canal injection of Triamicinolone Acetonide was added to group II. Open release of the carpal ligament was kept for patients of Group III. Treatment was given for the recommended period for each modality, and the follow up was for 6 months. Assessment was for the degree of pain relief and improvement in hand grip strength using the ppi scale and a dynamometer. Except three, all patients were females and the disease affected the right hand more than the left. After 6 months, results were: In group 1I 36% improvement of pain, but with no affect on hand grip strength. In group II, relief of pain reached up to 75% of patients with 12.76% average increase in hand grip strength. In group III surgery gave 82% improvement of pain with 20.5% average increase in hand grip strength. Open surgical release of the transverse carpal ligament should not be confined to patients with severe symptoms only. Conservative treatment is reserved for patients that either refuse surgery, or are unfit for surgery. Endoscopic release is not recommended for the time being

Local injection of dexamethasone for the treatment of carpal tunnel syndrome in pregnancy.

OBJECTIVE: To evaluate the results of 4 mg of dexamethasone acetate injections for the treatment of carpal tunnel syndrome in pregnancy. MATERIAL AND METHOD: Twenty-four pregnant volunteers who suffered from carpal tunnel syndrome occurring in the third trimester of their pregnancies were injected with 4 mg of dexamethasone acetate combined with 1% lidocaine into the carpal tunnels. The volunteers filled the Boston symptom severity questionnaire and were examined by Phalen's test, Semmes-Weinstein monofilament test, grip strength, and pinch strength before injection, one month after injection, and one month after delivery. RESULTS: There was significant improvement of symptoms, grip strength and pinch strength of the injected hand compared with the opposite side at one month after injection (p < 0.01). However, after delivery, the symptoms of carpal tunnel syndrome improved on both the injected and opposite hands. CONCLUSION: Carpal tunnel syndrome in pregnancy is generally resolved after delivery and, therefore, should be treated conservatively. The patient with severe symptoms can be treated with dexamethasone injection in the third trimester with good results.

Efficacy of splinting and oral steroids in the treatment of carpal tunnel syndrome: a prospective randomized clinical and electrophysiological study.

OBJECTIVE: To study the efficacy of splinting and oral steroids in the management of carpal tunnel syndrome (CTS). DESIGN: Prospective, randomized, open-label, clinical and electrophysiological study with 3-month follow-up. MATERIALS AND METHODS: Forty patients with CTS were randomly divided into splint group (N-20), wearing splint in neutral position for 4 weeks; and steroid group (N-20), who received oral prednisolone 20 mg/day for 2 weeks followed by 10 mg/day for 2 weeks. Clinical and electrophysiological evaluations were done at baseline and at 1-month and 3-month follow-up. Independent 't' test and paired 't' test were used for statistical analysis. OUTCOME MEASURES: Primary outcome measure was the symptom severity score and functional status score. Secondary outcome measures were median nerve sensory and motor distal latency and conduction velocity. RESULTS: At the end of 3 months, statistically significant improvement was seen in symptom severity score and functional status score in both groups (P<0.001). Median nerve sensory distal latency and conduction velocity also improved significantly in both the groups at 3 months. Improvement in motor distal latency was significant (P=0.001) at 3 months in steroid group, while insignificant improvement (P=0.139) was observed in splint group. On comparing the clinical and electrophysiological improvement between the two groups, except for the functional status score, there was no significant difference at 3-month follow-up. Improvement in functional status score was significantly more in steroid group (P=0.03). CONCLUSION: There was significant improvement in both groups, clinically as well as electrophysiologically, at 3 months. On comparing the efficacy of the two treatment methods, except for the functional status score, there was no significant difference between the two groups.

Efficacy of different drug penetration techniques on resolution of local inflammation

Drug administration can be done through different ways like injection, topical application, phonophoresis and iontophoresis. The aim of this study was to determine the effect of drug administration by iontophoresis and injection of 2% lidocaine with 4% dex…methasone sodium phosphate on pain perception, active range of motion [AROM], motor distal latency [MDL], and motor conduction velocity [MCV] of the median nerve in people with acute unilateral carpal tunnel syndrome [CTS]. Thirty subjects with acute unilateral CTS participated in this study. The results of this study showed significant improvement of wrist movement and reduction in pain and MDL in the acute CTS in treated groups versus control group. The results of this study may suggest the following: 1- The severity of symptoms does not correlate with severity of electrodiagnostic abnormalities. 2- lontophoresis may be considered as a preferable treatment technique in people with acute CTS

A preliminary trial of serratiopeptidase in patients with carpal tunnel syndrome.

OBJECTIVES: This study was planned to assess the response of serratiopeptidase in patients with carpal tunnel syndrome (CTS). METHODS: Twenty patients with CTS were evaluated clinically. After baseline electrophysiological studies, these patients were given serratiopeptidase 10 mg twice daily with initial short course of nimesulide. Clinical and electrophysiological reassessment was done after 6 weeks. RESULTS: Mean age was 43.9 years with male to female ratio of 1:2.33. Sixty five percent cases showed significant clinical improvement which was supported by significant improvement in electrophysiological parameters. Recurrence was reported in four cases. No significant side effect was observed. CONCLUSIONS: Serratiopeptidase therapy may proved to be a useful alternative mode of conservative treatment. Larger study may be further helpful to establish the role of serratiopeptidase in CTS.

Estudo comparativo entre o Tenoxicam e Diclofenaco sódico "Retard" em pacientes com lesöes por esforços repetitivos (LER) / Tenoxicam vs. Diclofenac Soidum Retard in the treatment of Repetitive effort injuries (READ)

Os autores realizaram um estudo duplo-cego, randomizado, com grupos paralelos, fazendo uma análise comparativa de eficácia e tolerabilidade entre dois AINE's comumente prescritos: o tenoxicam e o diclofenaco sódico "retard". Os pacientes estudados apresentavam doenças classificadas como Lesöes por Esforços Repetitivos (LER), que säo alteraçöes articulares próprias de determinadas profissöes e que vêm ganhando grande espaço entre aquelas afecçöes consideradas como Doenças Profissionais. Cinqüenta e sete desses pacientes concluíram o estudo e, pela avaliaçäo final dos parâmetros clínicos, a eficácia e tolerabilidade foram consideradas boas e comparáveis com ambos os tratamentos, em termos relativos. Considerando-se, porém, os resultados absolutos deste ensaio, nos parâmetros clínicos analisados, o tenoxicam mostrou-se superior ao diclofenaco sódico "retard"