Cortisone injections vs night splinting for carpal tunnel syndrome

Nonsurgical treatment for symptomatic carpal tunnel syndrome: A randomized clinical trial comparing local corticosteroid injection versus night orthosis. de Moraes, V. Y., et al. (2021) Level of Evidence: 1b- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Carpal tunnel conservative intervention - Cortisone injections vs splinting This is a randomised clinical trial assessing the effectiveness of night splinting vs corticosteroid injections on night paraesthesia, pain, function, and complications in people with carpal tunnel syndrome (CTS). Participants were included (N = 95) if they were over 40 years old and presented with at least 4 of the following six criteria: night paraesthesia in median nerve distribution of the hand, paraesthesia in median nerve distribution of the hand, atrophy of thenar muscles, positive Phalen's and Tinel's test, reduction in two-point discrimination (>6 mm). In addition, participants had to present with moderate to severe nerve conduction impairments on sensory and motor testing. Participants could have unilateral or bilateral symptoms, however, only the most affected limb was treated for the duration of the study. Outcome assessors were blinded to treatment allocation. Participants were randomised to either night splinting (n = 45), or non US guided corticosteroid injection (n = 50). Treatment effectiveness was assessed through self-reported night paraesthesia, pain and function were measured through the Boston-Levine questionnaire (BLQ), and complications were defined as a worsening of numbness at the injection site or skin tissue atrophy. Participants were assessed at baseline, 1 week, 3 and 6 months after treatment initiation. The results showed that corticosteroid injections reduced night paraesthesia to a clinically greater level compared to night splinting (see picture below). The same results were found for pain and function measured through the Boston-Levine questionnaire (BLQ) where corticosteroid injections were superior to splinting. Night splinting improved pain and function (BLQ) to a clinically relevant level but not night paraesthesia. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, corticosteroid injections appear to be superior to night splinting for our clients (≥ 40 years old) with moderate/severe carpal tunnel syndrome. This appears to be specially true for improvements in night paraesthesia. If clients decline a referral for a cortisone injections, splinting can still provide with some benefits (reduction in pain and disability) and other approaches such as manual therapy (mobilisation and tendon/nerve glides) directed at the upper limb appear to be as effective as surgery at one and four years follow up. The combination of manual therapy, nerve gliding exercises, night splinting, and education may provide even better results, and a this conservative management approach should be trialed before undergoing surgery. URL: Available through The Journal of Hand Surgery (American Volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Purpose: For carpal tunnel syndrome (CTS), local corticosteroid injection (corticosteroid), and/or wrist immobilization with night orthosis (orthosis) are commonly prescribed and are supported by strong evidence. The aim of this study was to compare orthosis versus corticosteroid for patients with CTS. Methods: A CTS diagnosis was made clinically and supported by electrodiagnostic study. Patients were randomly allocated to either orthosis or corticosteroid. Clinical assessments were performed before the intervention, within the first week of the intervention, and 1, 3, and 6 months after the intervention. Primary outcomes were improvement in nocturnal paresthesia and Boston-Levine questionnaire (BLQ) score. Secondary outcomes were pain assessed by visual analog scale and complications. Results: Of 100 patients enrolled in the study, 95 completed the planned follow-up (45 in the orthosis arm and 50 in the corticosteroid arm). Corticosteroid injections were superior to orthosis in remission of nocturnal paresthesia (remission rates at 1 month, 84.6% versus 43.83%; 3 months, 71.1% versus 40.4%; and 6 months, 80.3% versus 28.8%). The BLQ scores (functional and symptom subscales) were also more favorable for corticosteroid at 1, 3, and 6 months (minimal clinically important differences for Function > 0.5 and Symptom > 0.16). Pain scores were lower and favored the corticosteroid group. There were no complications in either group. Conclusions: Both options are effective in the short term. Corticosteroid is superior to orthosis for improving CTS-related nocturnal paresthesia, BLQ scores, and pain.