Research proposal for CTS

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There have been numerous studies for evaluating different treatmetns for CTS release..

Some reviews have showed that:

• 4 weeks nerve gliding exercises makes no difference (Akalin et al. 2002)
• Splint in 0° or 20°: no difference (Burke et al.1994; Walker et al.2000)
• 4 weeks splint or none. No difference (Manente et al. 2001)
• Internal neurolysis. No difference (Mackinnon et al. 1991; Chapell et al. 2003)

Primary outcome measures used in previous studies were:
- the Levine Carpal Tunnel Syndrome Questionnaire(Levine et al. 1993; Hoefnagels et al. 1997), and the secondary outcome measures were electrophysiological data and the Purdue pegboard test.(Irvine et al. 2004)
- Change in wrist, hand, and/or finger discomfort, carpal tunnel symptom severity index, median sensory nerve function, and the percentage of subjects who had carpal tunnel release surgery.(Werner et al. 2005)
- General improvement, number of nights waking up due to symptoms, and severity of symptoms.(Gerritsen et al. 2002)
- parameters of Nerve Conduction Studies (NCS) improve significantly after treatment for CTS, but the modest correlations between neurophysiologic and clinical outcome measures do not support that NCS are routinely performed in clinical practice to evaluate treatment effects.(Schrijver et al. 2005)
- Patient Evaluation Measure questionnaire (PEM) as an outcome measure in carpal tunnel syndrome. The PEM was compared to the DASH questionnaire and to objective measurements of hand function. Grip strength, static two-point discrimination and the nine-hole peg test were measured. There was a significant correlation between individual items of the PEM and the objective measures. There was also strong correlation between PEM and DASH scores. The PEM showed a greater responsiveness to change (effect size 0.97) than the DASH score (effect size 0.49). The PEM correlates well with objective measures of hand function and the DASH score when used in carpal tunnel syndrome. It is more responsive to change than the DASH score. It is very simple to complete and score and is an appropriate and practical outcome measure in carpal tunnel syndrome.(Hobby et al. 2005)
- Patients were followed up at 6 and 20 weeks. The primary outcome was symptom relief in terms of the Global Symptom Score (GSS), which rates symptoms on a scale of 0 (no symptoms) to 50 (most severe).(Hui et al. 2005)
- Symptom severity scale.(Walker et al. 2000)
- Tinel
- Phalen (full flexion, 60 sec)

Suggested Material and Methods
- Pts tested pre-operatively
- Two intervention (either surgical or therapy) will be evaluated.

    Options:
        -Surgical: compare microscopic, line of incision, location
        - Therapy: therapy ; if pain increases: splint, advice conc. work, sports
        - If difficulty moving fingers; exercises,
        - Elevation of hand
        - no therapy (only surgical instructions)

Outcome measures:
        Questionnaire; concerning symptoms esp. pain (Levine)
        Grip strength (N)
        Semmes Weinstein filaments
        Nine-hole pegboard (sec)

        Return to Work (days)
        Pt satisfaction
        Complications (eg CRPS)

References
Akalin E, El O, Peker O, Senocak O, Tamci S, Gulbahar S, Cakmur R, Oncel S. Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises. Am J Phys Med Rehabil 2002;81(2):108-113.

Burke DT, Burke MM, Stewart GW, Cambre A. Splinting for carpal tunnel syndrome: in search of the optimal angle. Arch Phys Med Rehabil 1994;75(11):1241-1244.

Chapell R, Coates V, Turkelson C. Poor outcome for neural surgery (epineurotomy or neurolysis) for carpal tunnel syndrome compared with carpal tunnel release alone: a meta-analysis of global outcomes. Plast Reconstr Surg 2003;112(4):983-990; discussion 991-982.

Gerritsen AA, de Vet HC, Scholten RJ, Bertelsmann FW, de Krom MC, Bouter LM. Splinting vs surgery in the treatment of carpal tunnel syndrome: a randomized controlled trial. Jama 2002;288(10):1245-1251.

Hobby JL, Watts C, Elliot D. Validity and responsiveness of the patient evaluation measure as an outcome measure for carpal tunnel syndrome. J Hand Surg [Br] 2005;30(4):350-354.

Hoefnagels WA, van Kleef JG, Mastenbroek GG, de Blok JA, Breukelman AJ, de Krom MC. [Surgical treatment of carpal tunnel syndrome: endoscopic or classical (open)? A prospective randomized trial]. Ned Tijdschr Geneeskd 1997;141(18):878-882.

Hui AC, Wong S, Leung CH, Tong P, Mok V, Poon D, Li-Tsang CW, Wong LK, Boet R. A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome. Neurology 2005;64(12):2074-2078.

Irvine J, Chong SL, Amirjani N, Chan KM. Double-blind randomized controlled trial of low-level laser therapy in carpal tunnel syndrome. Muscle Nerve 2004;30(2):182-187.

Levine DW, Simmons BP, Koris MJ, Daltroy LH, Hohl GG, Fossel AH, Katz JN. A self-administered questionnaire for the assessment of severity of symptoms and

functional status in carpal tunnel syndrome. J Bone Joint Surg Am 1993;75(11):1585-1592.

Mackinnon SE, McCabe S, Murray JF, Szalai JP, Kelly L, Novak C, Kin B, Burke GM. Internal neurolysis fails to improve the results of primary carpal tunnel decompression. J Hand Surg [Am] 1991;16(2):211-218.

Manente G, Torrieri F, Di Blasio F, Staniscia T, Romano F, Uncini A. An innovative hand brace for carpal tunnel syndrome: a randomized controlled trial. Muscle Nerve 2001;24(8):1020-1025.

Schrijver HM, Gerritsen AA, Strijers RL, Uitdehaag BM, Scholten RJ, de Vet HC, Bouter LM. Correlating nerve conduction studies and clinical outcome measures on carpal tunnel syndrome: lessons from a randomized controlled trial. J Clin Neurophysiol 2005;22(3):216-221.

Walker WC, Metzler M, Cifu DX, Swartz Z. Neutral wrist splinting in carpal tunnel syndrome: a comparison of night-only versus full-time wear instructions. Arch Phys Med Rehabil 2000;81(4):424-429.

Werner RA, Franzblau A, Gell N. Randomized controlled trial of nocturnal splinting for active workers with symptoms of carpal tunnel syndrome. Arch Phys Med Rehabil 2005;86(1):1-7.