OBJECTIVE: To evaluate the comparative efficacy of various conservative treatments for carpal tunnel syndrome (CTS), including manual therapy (MT), local steroid injections, platelet-rich plasma (PRP) injections, extracorporeal shock wave therapy, and low-level laser therapy, through a comprehensive network meta-analysis.
DATA SOURCES: PubMed, Web of Science, Cochrane Library, Embase, SPORTDiscus, and China National Knowledge Infrastructure databases were searched to identify published studies until April 2024.
STUDY SELECTION: Randomized controlled trials comparing the efficacy of conservative CTS treatments in individuals with CTS were included.
DATA EXTRACTION: Data from the included articles were extracted independently by 2 researchers, with any disagreements resolved through consultation with a third author. The extracted data included the first author's name, country/region, publication year, sample size, participants' age, disease severity, symptom duration, intervention parameters, follow-up period, and reported outcomes.
DATA SYNTHESIS: A total of 49 randomized controlled trials involving 11 conservative treatments and 3323 participants were included. The network meta-analysis showed that MT demonstrated the highest efficacy in both short-term and medium-term pain relief with surface under the cumulative ranking curve values of 87.6% and 99.3%, respectively. Dextrose 5% in water and PRP were closely followed in terms of efficacy. Compared to control groups, low-level laser therapy (standardized mean difference=-1.45; 95% CI, -2.16 to -0.74) and extracorporeal shock wave therapy (standardized mean difference=-1.03; 95% CI, -1.86 to -0.20) also showed significant benefits.
CONCLUSIONS: This study provides robust evidence that MT and dextrose 5% in water injections are the most effective conservative treatments for CTS which offer valuable insights for clinical decision-making. Further research is needed to assess the long-term efficacy and cost-effectiveness of these interventions.
| Discipline Area | Score |
|---|---|
| Rehab Clinician (OT/PT) |  |
Rehab Clinician (OT/PT) rater
A disappointing finding of this very thorough review is that prediction intervals are very wide in all meta-analyses, indicating inconsistency of results and a possible non-significant effect. Uncertainty about the overall risk of bias (particularly in outcome measurement) for most of the included studies is a further cause for concern.
Rehab Clinician (OT/PT) rater
The apparent absence of a detailed analysis of the explicit heterogeneity of CTS observed in this review/meta-analysis would benefit from a more helpful stratification with objective reporting of duration and associations with clinical symptoms (including occupational factors, pregnancy and thyroid function, insulin-dependent diabetes mellitus, and other peripheral neuropathies) and associated conduction studies, MRI analysis of carpal tunnel dimensions, MRI analysis of the x-sectional area of the media nerve crossing beneath the transverse ligament, analysis of regional (wrist/forearm/superior thoracic inlet/cervical spine) somatic dysfunction arising from/with median n. nerve irritation, and dependence on clinical aids such as nocturnal wrist splinting.
Rehab Clinician (OT/PT) rater
A significant advantage of this study is its ability to conduct both direct and indirect comparisons between interventions through a network meta-analysis. Recent meta-analyses and clinical guidelines indicate that manual therapy is increasingly superseding traditional electrotherapy modalities in the physiotherapy management of carpal tunnel syndrome; however, it is noteworthy that research on the efficacy of therapeutic exercises in this population remains limited, or such exercises are occasionally found to be inferior to passive modalities. Although manual therapy is prominent, the diversity and lack of standardization among applied techniques — including mobilization, neurodynamic manipulation, myofascial therapy, and reflexology — present a substantial methodological challenge. Consequently, this field continues to pose significant unresolved questions for clinicians, particularly for physiotherapists.
, McMaster University