Karpal Tünel Sendromu/ Carpal Tunnel Syndrome
Başlık: Effect of extracorporeal shockwave therapy on carpal tunnel syndrome
Background:
Although several trials have reported the use of extracorporeal shock wave therapy (ESWT) for mild to moderate carpal tunnel syndrome (CTS), little is known about the efficacy of ESWT. Thus, we performed a meta-analysis to evaluate whether ESWT can improve symptoms, functional outcomes, and electrophysiologic parameters in CTS.
Methods:
Six randomized controlled trials investigating the effect of ESWT on CTS were retrieved from PubMed, Embase, and the Cochrane Library. We performed a pairwise meta-analysis using fixed- or random-effects models.
Results:
ESWT showed significant overall effect size compared to the control (overall Hedge g pooled standardized mean difference (SMD) = 1.447; 95% confidence interval [CI], 0.439–2.456; P = .005). Symptoms, functional outcomes, and electrophysiologic parameters all improved with ESWT treatment. However, there was no obvious difference between the efficacy of ESWT and local corticosteroid injection (pooled SMD = 0.418; 95% CI, −0.131 to 0.968; P = .135). A publication bias was not evident in this study.
Conclusion:
Our meta-analysis revealed that ESWT can improve symptoms, functional outcomes, and electrophysiologic parameters in patients with CTS. Further research is needed to confirm the long-term effects and the optimal ESWT protocol for CTS.
Keywords: carpal tunnel syndrome, extracorporeal shock wave therapy, median neuropathy, meta-analysis1. Introduction
Carpal tunnel syndrome (CTS) is a clinical syndrome caused by compression of the median nerve at the wrist. It is the most common entrapment neuropathy in adults.[1] Clinical features of CTS include nocturnal pain, numbness, tingling sensation in the median nerve dermatome, and the diagnosis is confirmed by these typical clinical symptoms, along with electrodiagnostic studies.[2,3] While the pathophysiology of CTS is not fully understood, ischemic injury due to increased carpal tunnel pressure is considered to be the most crucial factor.[3,4] Repetitive wrist movements, obesity, rheumatoid arthritis, diabetes mellitus, and menopause are known risk factors of CTS.[3,5]
Treatment options for CTS consist of wrist splints, physical modalities, local corticosteroid injections, and surgical treatments.[6,7,8] For mild to moderate CTS, conservative nonsurgical treatments are recommended prior to surgery.[9] When conservative treatment fails, surgical treatment can be considered.[10] The effects of a wrist splint, local corticosteroid injection, and surgical treatment have been demonstrated in multiple studies.[5] However, other conservative treatments such as oral steroids, therapeutic ultrasound, and low level laser therapy have limited evidence of being effective.[5,11]
Recently, extracorporeal shock wave therapy (ESWT) has been used for the treatment of CTS as a novel and noninvasive method. Since Romeo et al first used ESWT for pillar pain after carpal tunnel release,[12] a few randomized controlled studies have also reported that ESWT can improve functional outcomes and electrophysiologic parameters. However, there is still a lack of clear evidence regarding ESWT's effectiveness for CTS. Therefore, we performed this meta-analysis to evaluate the efficacy of ESWT for CTS. The aim of this study was to compare the improvement in symptoms, functional outcomes, and electrophysiologic parameters on patients with CTS between ESWT and control treatment groups. We hypothesized that ESWT would show better symptomatic, functional, and electrophysiologic improvements than other conservative treatment approaches.
2. Methods
2.1. Search strategy
The meta-analysis was conducted in line with the updated Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines.[13] PubMed-Medline, Embase, and Cochrane Library searches were performed in August 2018 using the following key terms: (Carpal tunnel syndrome OR Median neuropathy OR Entrapment neuropathy OR Median neuritis) AND (Extracorporeal Shockwave Therapy OR Shockwave Therapy OR Shock wave OR ESWT) AND Randomized controlled trial. An overview of the search strategy is presented in Supplementary Appendix 1. We included all randomized controlled trials investigating the effect of ESWT on CTS. We imposed no language restriction. We also searched for unpublished and grey literature using the databases/trial registries: World Health Organization Clinical Trial Register, EU clinical trials register, ClinicalTrials.gov, and OpenGrey.
2.2. Study selection criteria
Identified records were saved to EndNote software (X7.2; Thomson Reuters). Two independent reviewers (JCK, SYL) screened all titles and abstracts to identify relevant investigations. Inclusion criteria were articles reporting a randomized controlled trial with at least 3 months follow-up that described the effect of ESWT on CTS. There were no limitations in types of ESWT. Reviews, basic science articles, comments, letters, and protocols were excluded. When updates of earlier studies were available, we used only the most recent updates.
2.3. Outcome measures and data extraction
The primary outcome of interest was broadly defined any measure of symptoms which included pain, numbness, tingling sensation, or weakness. If a trial reported multiple measures of symptoms, the most composite measure of symptoms analyzed by a multidimensional instrument was chosen as the primary outcome measure. The secondary outcome of this study was a functional score, such as Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) or Disabilities of the Arm, Shoulder, and Hand (DASH), motor component in electrophysiologic studies of the median nerve, such as distal motor latency or compound motor action potential amplitude, and sensory component in electrophysiologic studies of the median nerve, such as distal sensory latency, sensory nerve action potential amplitude, or sensory nerve conduction velocity. We combined the values of effect size in each study as one pooled effect size.[14] Because no differences between designs of the selected studies are found, effect sizes could be combined.[15] For every eligible study, the following data were extracted and entered into a spreadsheet by the 2 reviewers (JCK, SYL): first author's family name, year of publication, number of patients, mean age of participants, enrollment time, ESWT type and treatment intensity/frequency/duration, and follow-up duration.
2.4. Quality assessment and publication bias
Two authors (JCK, SYL) independently evaluated study quality using criteria described in the Cochrane Handbook for Systematic Reviews of Interventions.[16] Criteria included the following 7 items: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome data, incomplete outcome data addressed, selective reporting, and other biases. We assessed publication bias using Begg funnel plot[17] and Egger test.[18]
2.5. Statistical analysis
Effect sizes were computed as standardized mean difference (SMD) measures representing the magnitude of the pretest–posttest difference for each outcome. SMD was computed separately for all available control and treatment groups for each study. Heterogeneity between comparable studies was tested with the Chi-squared (χ 2) and I 2 tests. Values of P > .1 and I 2 < 50% were considered statistically significant. Because there was a significant heterogeneity among the 6 studies (P < .001 and I 2 = 91.9%), we used a random-effects meta-analysis to quantify the pooled effect size of the included studies. In each analysis by outcome parameters, symptoms (P < .001 and I 2 = 93.4%), functional score (P < .001 and I 2 = 95.0%), motor component (P = .039 and I 2 = 64.2%), and sensory component (P < .001 and I 2 = 83.5%) were also analyzed using the random-effects model. Additionally, we performed subgroup analyses by the type of control treatment (steroid injection and sham ESWT) and ESWT type (radial and focused). The Q test for heterogeneity was used when performing subgroup analyses. All analyses were performed using Comprehensive Meta-Analysis Software (version 3.3; Biostat, Englewood, NJ). This study was exempted from Institutional Review Board review since it did not involve human subjects.
3. Results
3.1. Description of included studies
The primary database search yielded 48 records. After duplicates were removed, the titles and abstracts of 13 articles were initially screened, and only 8 were selected for full-text review. The full text articles were read, and 6 were considered relevant by qualitative analysis.[19,20,21,22,23,24] Studies selected for final inclusion (or exclusion) are shown in Figure Figure1,1, and the characteristics of the included studies are summarized in Table Table1.1. In terms of quantitative analysis, these 6 studies (published from 2013 to 2018) fulfilled our inclusion criteria. Studies identified for meta-analysis included 281 participants. Study sample sizes varied from 25 to 60 wrists (13–34 cases and 12–30 controls). The selected studies represented a total of 145 wrists treated by ESWT and 136 wrists treated conservatively. The follow-up duration ranged from 12 to 24 weeks.
