Radial Extracorporeal Shock Wave Therapy in the Treatment of Carpal Tunnel Syndrome
Condition: Carpal Tunnel Syndrome
MeSH terms: Carpal Tunnel Syndrome; Syndrome
Study type: Interventional

Summary: 
      Carpal tunnel syndrome (CTS) is the most common of all entrapment syndromes with a prevalence
      of 1-5%. Electrodiagnostic testing is used to make a definite diagnosis. The mainstay of the
      pathophysiology of CTS includes mechanical damage to the median nerve due to build up of
      pressure in the carpal tunnel and nerve ischaemia. Physical therapy (PT) in particular is the
      conventional non-surgical treatment of choice in the management of mild to moderate CTS,
      resulting in pain reduction and improved function.

      Extracorporeal shock wave therapy (ESWT) is a non invasive treatment method in which high
      frequency sound waves are applied to the body. The mechanism of action of ESWT in the
      treatment of CTS remains largely unknown.

      Eventhough there are many therapeutic options in the treatment of mild to moderate CTS, there
      is no consensus on the most effective treatment (4). ESWT has become a desirable treatment
      option in recent years. However, due to small patients numbers in trials to date and a lack
      of placebo controlled studies, the efficacy of this treatment option is still under debate.
      This study aims to compare the efficacy of RESWT to the recommended conventional PT
      modalities, including therapeutic US, in the treatment of CTS with regards to nociceptive and
      neuropathic pain, functionality and nerve conduction study outcomes.
    

Detailed description: 
      Carpal tunnel syndrome (CTS) is the most common of all entrapment syndromes with a prevalence
      of 1-5%. CTS describes the compression of the median nerve as it travels through the carpal
      tunnel of the wrist, largely resulting in sensory symptoms of paraesthesia and pain in the
      areas of the hand innervated by the nerve. CTS can also lead to muscle atrophy, loss of motor
      function and disability of the hand. Electrodiagnostic testing is used to make a definite
      diagnosis. The mainstay of the pathophysiology of CTS includes mechanical damage to the
      median nerve due to build up of pressure in the carpal tunnel and nerve ischaemia. Chronic
      compression of the median nerve also results in neuronal depolarisation and the release of
      neuropeptides such as substance P and calcitonin-gene-related peptide. These neuropeptides
      stimulate the release of endothelial nitric oxide thus triggering vasodilatation and
      neurogenic inflammation .

      Management of CTS depends on disease severity. Physical therapy (PT) in particular is the
      conventional non-surgical treatment of choice in the management of mild to moderate CTS,
      resulting in pain reduction and improved function. Recommended PT modalities include laser,
      ultrasound and liquid paraffin therapy. US therapy in particular has given satisfactory
      results in the treatment of mild to moderate CTS. The biophysical effects of US have been
      shown to trigger nerve regeneration and healing.

      Extracorporeal shock wave therapy (ESWT) is a non invasive treatment method in which high
      frequency sound waves are applied to the body . ESWT can be divided into radial (RESWT) and
      focused (FESWT) based on the design of the reflector and resultant pressure and energy
      applied. Animal studies have shown that ESWT, and especially RESWT can be successfully used
      in the treatment of peripheral nerve lesions, improving nerve regeneration and functional
      activity . Human studies on its uses in the treatment of peripheral neuropathies such as
      interdigital neuroma, distally symmetric polyneuropathy and CTS have also given promising
      results . The mechanism of action of ESWT in the treatment of CTS remains largely unknown.
      However, it is believed that the antiinflammatory, angio- and neuro-genic, effects of ESWT
      encourages tissue regeneration in CTS thus reducing the patient's symptoms and promoting an
      improvement in function. Moreover, RESWT rather than FESWT maybe the better therapeutic
      option in CTS as it can be applied to a wider area, incorporating both the median nerve and
      surrounding tissues.

      Eventhough there are many therapeutic options in the treatment of mild to moderate CTS, there
      is no consensus on the most effective treatment. ESWT has become a desirable treatment option
      in recent years. However, due to small patients numbers in trials to date and a lack of
      placebo controlled studies, the efficacy of this treatment option is still under debate. This
      study aims to compare the efficacy of RESWT to the recommended conventional PT modalities,
      including therapeutic US, in the treatment of CTS with regards to nociceptive and neuropathic
      pain, functionality and nerve conduction study outcomes.
    

Intervention name(s): splint and home exercise; RESWT; physical therapy
Intervention type(s): Device; Device; Device
Intervention description(s): Each patient will be given a home exercise program of wrist range of motion, wrist stretch, wrist isometric strengthening and median nerve glide exercises to be performed daily for the duration of the study; RESWT at a pressure of 4 bars, a frequency of 5Hz and 2000 hits in total will be applied 2cm proximal to the median nerve, with the probe directed towards the palm, diffusely over the pisiform.; 20 minutes of liquid paraffin treatment of the hand, 1.5watt/cm2 therapeutic ultrasound applied to the volar surface of the wrist for 5 minutes and 20 minutes of transcutaneous electrical nerve stimulation (TENS) on five consecutive days of the week for a total of fifteen sessions over 3 weeks
Other intervention name(s): splint and home exercise; splint and home exercise
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: This study aims to compare the efficacy of RESWT to the recommended conventional PT modalities, including therapeutic US, in the treatment of CTS with regards to nociceptive and neuropathic pain, functionality and nerve conduction study outcomes.
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Extracorporeal shock wave therapy; Carpal Tunnel Syndrome; physical therapy