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. 2003;2003(1):CD003219.
doi: 10.1002/14651858.CD003219.

Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome

Affiliations

Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome

D O'Connor et al. Cochrane Database Syst Rev. 2003.

Abstract

Background: Non-surgical treatment for carpal tunnel syndrome is frequently offered to those with mild to moderate symptoms. The effectiveness and duration of benefit from non-surgical treatment for carpal tunnel syndrome remain unknown.

Objectives: To evaluate the effectiveness of non-surgical treatment (other than steroid injection) for carpal tunnel syndrome versus a placebo or other non-surgical, control interventions in improving clinical outcome.

Search strategy: We searched the Cochrane Neuromuscular Disease Group specialised register (searched March 2002), MEDLINE (searched January 1966 to February 7 2001), EMBASE (searched January 1980 to March 2002), CINAHL (searched January 1983 to December 2001), AMED (searched 1984 to January 2002), Current Contents (January 1993 to March 2002), PEDro and reference lists of articles.

Selection criteria: Randomised or quasi-randomised studies in any language of participants with the diagnosis of carpal tunnel syndrome who had not previously undergone surgical release. We considered all non-surgical treatments apart from local steroid injection. The primary outcome measure was improvement in clinical symptoms after at least three months following the end of treatment.

Data collection and analysis: Three reviewers independently selected the trials to be included. Two reviewers independently extracted data. Studies were rated for their overall quality. Relative risks and weighted mean differences with 95% confidence intervals were calculated for the primary and secondary outcomes in each trial. Results of clinically and statistically homogeneous trials were pooled to provide estimates of the efficacy of non-surgical treatments.

Main results: Twenty-one trials involving 884 people were included. A hand brace significantly improved symptoms after four weeks (weighted mean difference (WMD) -1.07; 95% confidence interval (CI) -1.29 to -0.85) and function (WMD -0.55; 95% CI -0.82 to -0.28). In an analysis of pooled data from two trials (63 participants) ultrasound treatment for two weeks was not significantly beneficial. However one trial showed significant symptom improvement after seven weeks of ultrasound (WMD -0.99; 95% CI -1.77 to - 0.21) which was maintained at six months (WMD -1.86; 95% CI -2.67 to -1.05). Four trials involving 193 people examined various oral medications (steroids, diuretics, nonsteroidal anti-inflammatory drugs) versus placebo. Compared to placebo, pooled data for two-week oral steroid treatment demonstrated a significant improvement in symptoms (WMD -7.23; 95% CI -10.31 to -4.14). One trial also showed improvement after four weeks (WMD -10.8; 95% CI -15.26 to -6.34). Compared to placebo, diuretics or nonsteroidal anti-inflammatory drugs did not demonstrate significant benefit. In two trials involving 50 people, vitamin B6 did not significantly improve overall symptoms. In one trial involving 51 people yoga significantly reduced pain after eight weeks (WMD -1.40; 95% CI -2.73 to -0.07) compared with wrist splinting. In one trial involving 21 people carpal bone mobilisation significantly improved symptoms after three weeks (WMD -1.43; 95% CI -2.19 to -0.67) compared to no treatment. In one trial involving 50 people with diabetes, steroid and insulin injections significantly improved symptoms over eight weeks compared with steroid and placebo injections. Two trials involving 105 people compared ergonomic keyboards versus control and demonstrated equivocal results for pain and function. Trials of magnet therapy, laser acupuncture, exercise or chiropractic care did not demonstrate symptom benefit when compared to placebo or control.

Reviewer's conclusions: Current evidence shows significant short-term benefit from oral steroids, splinting, ultrasound, yoga and carpal bone mobilisation. Other non-surgical treatments do not produce significant benefit. More trials are needed to compare treatments and ascertain the duration of benefit.

PubMed Disclaimer

Conflict of interest statement

None

Figures

1.1
1.1. Analysis
Comparison 1 HAND SPLINT (BRACE) VS CONTROL, Outcome 1 Symptoms.
1.2
1.2. Analysis
Comparison 1 HAND SPLINT (BRACE) VS CONTROL, Outcome 2 Hand function.
1.3
1.3. Analysis
Comparison 1 HAND SPLINT (BRACE) VS CONTROL, Outcome 3 Self‐reported improvement.
2.1
2.1. Analysis
Comparison 2 FULLTIME VS NOCTURNAL WRIST SPLINT, Outcome 1 Symptoms.
2.2
2.2. Analysis
Comparison 2 FULLTIME VS NOCTURNAL WRIST SPLINT, Outcome 2 Hand function.
3.1
3.1. Analysis
Comparison 3 NEUTRAL VS EXTENSION WRIST SPLINT, Outcome 1 Symptom relief.
4.1
4.1. Analysis
Comparison 4 ULTRASOUND VS PLACEBO, Outcome 1 Pain.
4.2
4.2. Analysis
Comparison 4 ULTRASOUND VS PLACEBO, Outcome 2 Symptoms.
4.3
4.3. Analysis
Comparison 4 ULTRASOUND VS PLACEBO, Outcome 3 Nocturnal waking.
4.4
4.4. Analysis
Comparison 4 ULTRASOUND VS PLACEBO, Outcome 4 Sensation.
4.5
4.5. Analysis
Comparison 4 ULTRASOUND VS PLACEBO, Outcome 5 Grip strength (kg).
4.6
4.6. Analysis
Comparison 4 ULTRASOUND VS PLACEBO, Outcome 6 Pinch strength (kg).
4.7
4.7. Analysis
Comparison 4 ULTRASOUND VS PLACEBO, Outcome 7 Self‐reported improvement.
4.8
4.8. Analysis
Comparison 4 ULTRASOUND VS PLACEBO, Outcome 8 Median nerve conduction.
5.1
5.1. Analysis
Comparison 5 ULTRASOUND VS ULTRASOUND (VARYING INTENSITY), Outcome 1 Pain.
5.2
5.2. Analysis
Comparison 5 ULTRASOUND VS ULTRASOUND (VARYING INTENSITY), Outcome 2 Symptoms.
5.3
5.3. Analysis
Comparison 5 ULTRASOUND VS ULTRASOUND (VARYING INTENSITY), Outcome 3 Nocturnal waking.
6.1
6.1. Analysis
Comparison 6 ULTRASOUND VS ULTRASOUND (VARYING FREQUENCY), Outcome 1 Improved pain.
6.2
6.2. Analysis
Comparison 6 ULTRASOUND VS ULTRASOUND (VARYING FREQUENCY), Outcome 2 Improved paresthesia.
6.3
6.3. Analysis
Comparison 6 ULTRASOUND VS ULTRASOUND (VARYING FREQUENCY), Outcome 3 Improved superficial sensation.
6.4
6.4. Analysis
Comparison 6 ULTRASOUND VS ULTRASOUND (VARYING FREQUENCY), Outcome 4 Improved grasp.
6.5
6.5. Analysis
Comparison 6 ULTRASOUND VS ULTRASOUND (VARYING FREQUENCY), Outcome 5 Improved Tinel's sign.
6.6
6.6. Analysis
Comparison 6 ULTRASOUND VS ULTRASOUND (VARYING FREQUENCY), Outcome 6 Improved Phalen's sign.
7.1
7.1. Analysis
Comparison 7 ERGONOMIC KEYBOARD VS PLACEBO/CONTROL, Outcome 1 Pain.
7.2
7.2. Analysis
Comparison 7 ERGONOMIC KEYBOARD VS PLACEBO/CONTROL, Outcome 2 Pain (change scores).
7.3
7.3. Analysis
Comparison 7 ERGONOMIC KEYBOARD VS PLACEBO/CONTROL, Outcome 3 Hand function.
7.4
7.4. Analysis
Comparison 7 ERGONOMIC KEYBOARD VS PLACEBO/CONTROL, Outcome 4 Hand function (change scores).
7.5
7.5. Analysis
Comparison 7 ERGONOMIC KEYBOARD VS PLACEBO/CONTROL, Outcome 5 Improved Phalen's sign.
7.6
7.6. Analysis
Comparison 7 ERGONOMIC KEYBOARD VS PLACEBO/CONTROL, Outcome 6 Improved Tinel's sign.
7.7
7.7. Analysis
Comparison 7 ERGONOMIC KEYBOARD VS PLACEBO/CONTROL, Outcome 7 Phalen test time (seconds).
7.8
7.8. Analysis
Comparison 7 ERGONOMIC KEYBOARD VS PLACEBO/CONTROL, Outcome 8 Median nerve conduction: palm‐wrist sensory latency (ms).
8.1
8.1. Analysis
Comparison 8 DIURETIC VS PLACEBO, Outcome 1 Symptoms.
8.2
8.2. Analysis
Comparison 8 DIURETIC VS PLACEBO, Outcome 2 Symptom improvement.
9.1
9.1. Analysis
Comparison 9 NSAID VS PLACEBO, Outcome 1 Symptoms.
10.1
10.1. Analysis
Comparison 10 ORAL STEROID (PREDNISOLONE OR PREDNISONE) VS PLACEBO, Outcome 1 Symptoms.
11.1
11.1. Analysis
Comparison 11 DIURETIC VS NSAID, Outcome 1 Symptoms.
12.1
12.1. Analysis
Comparison 12 DIURETIC VS ORAL STEROID (PREDNISOLONE), Outcome 1 Symptoms.
13.1
13.1. Analysis
Comparison 13 NSAID VS ORAL STEROID (PREDNISOLONE), Outcome 1 Symptoms.
14.1
14.1. Analysis
Comparison 14 VITAMIN B6 (PYRIDOXINE) VS PLACEBO, Outcome 1 Symptom improvement.
14.2
14.2. Analysis
Comparison 14 VITAMIN B6 (PYRIDOXINE) VS PLACEBO, Outcome 2 Nocturnal discomfort.
14.3
14.3. Analysis
Comparison 14 VITAMIN B6 (PYRIDOXINE) VS PLACEBO, Outcome 3 Finger swelling.
14.4
14.4. Analysis
Comparison 14 VITAMIN B6 (PYRIDOXINE) VS PLACEBO, Outcome 4 Movement discomfort.
14.5
14.5. Analysis
Comparison 14 VITAMIN B6 (PYRIDOXINE) VS PLACEBO, Outcome 5 Hand co‐ordination.
14.6
14.6. Analysis
Comparison 14 VITAMIN B6 (PYRIDOXINE) VS PLACEBO, Outcome 6 Improved Phalen's sign.
14.7
14.7. Analysis
Comparison 14 VITAMIN B6 (PYRIDOXINE) VS PLACEBO, Outcome 7 Improved Tinel's sign.
14.8
14.8. Analysis
Comparison 14 VITAMIN B6 (PYRIDOXINE) VS PLACEBO, Outcome 8 Median nerve conduction: distal latency (ms).
14.9
14.9. Analysis
Comparison 14 VITAMIN B6 (PYRIDOXINE) VS PLACEBO, Outcome 9 Median nerve conduction: motor amplitude (mV).
14.10
14.10. Analysis
Comparison 14 VITAMIN B6 (PYRIDOXINE) VS PLACEBO, Outcome 10 Median nerve conduction: motor conduction velocity (m/s).
15.1
15.1. Analysis
Comparison 15 NERVE AND TENDON GLIDING EXERCISES (PLUS WRIST SPLINT) VS CONTROL (WRIST SPLINT ONLY), Outcome 1 Symptoms.
15.2
15.2. Analysis
Comparison 15 NERVE AND TENDON GLIDING EXERCISES (PLUS WRIST SPLINT) VS CONTROL (WRIST SPLINT ONLY), Outcome 2 Hand function.
15.3
15.3. Analysis
Comparison 15 NERVE AND TENDON GLIDING EXERCISES (PLUS WRIST SPLINT) VS CONTROL (WRIST SPLINT ONLY), Outcome 3 Grip strength (lbs).
15.4
15.4. Analysis
Comparison 15 NERVE AND TENDON GLIDING EXERCISES (PLUS WRIST SPLINT) VS CONTROL (WRIST SPLINT ONLY), Outcome 4 Pinch strength (lbs).
15.5
15.5. Analysis
Comparison 15 NERVE AND TENDON GLIDING EXERCISES (PLUS WRIST SPLINT) VS CONTROL (WRIST SPLINT ONLY), Outcome 5 Static two‐point discrimination (mm).
15.6
15.6. Analysis
Comparison 15 NERVE AND TENDON GLIDING EXERCISES (PLUS WRIST SPLINT) VS CONTROL (WRIST SPLINT ONLY), Outcome 6 Positive Phalen's sign.
15.7
15.7. Analysis
Comparison 15 NERVE AND TENDON GLIDING EXERCISES (PLUS WRIST SPLINT) VS CONTROL (WRIST SPLINT ONLY), Outcome 7 Positive Tinel's sign.
15.8
15.8. Analysis
Comparison 15 NERVE AND TENDON GLIDING EXERCISES (PLUS WRIST SPLINT) VS CONTROL (WRIST SPLINT ONLY), Outcome 8 High patient satisfaction.
16.1
16.1. Analysis
Comparison 16 YOGA VS WRIST SPLINT, Outcome 1 Improvement in nocturnal waking.
16.2
16.2. Analysis
Comparison 16 YOGA VS WRIST SPLINT, Outcome 2 Pain.
16.3
16.3. Analysis
Comparison 16 YOGA VS WRIST SPLINT, Outcome 3 Improved Phalen's sign.
16.4
16.4. Analysis
Comparison 16 YOGA VS WRIST SPLINT, Outcome 4 Improved Tinel's sign.
16.5
16.5. Analysis
Comparison 16 YOGA VS WRIST SPLINT, Outcome 5 Grip strength (mmHg).
17.1
17.1. Analysis
Comparison 17 NEURODYNAMIC MOBILISATION VS CONTROL, Outcome 1 Symptoms.
17.2
17.2. Analysis
Comparison 17 NEURODYNAMIC MOBILISATION VS CONTROL, Outcome 2 Improved pain.
17.3
17.3. Analysis
Comparison 17 NEURODYNAMIC MOBILISATION VS CONTROL, Outcome 3 Improved hand function.
17.4
17.4. Analysis
Comparison 17 NEURODYNAMIC MOBILISATION VS CONTROL, Outcome 4 Active wrist flexion (degrees).
17.5
17.5. Analysis
Comparison 17 NEURODYNAMIC MOBILISATION VS CONTROL, Outcome 5 Active wrist extension (degrees).
17.6
17.6. Analysis
Comparison 17 NEURODYNAMIC MOBILISATION VS CONTROL, Outcome 6 Improvement in upper limb tension test (ULTT2a).
17.7
17.7. Analysis
Comparison 17 NEURODYNAMIC MOBILISATION VS CONTROL, Outcome 7 Need for surgical release.
18.1
18.1. Analysis
Comparison 18 CARPAL BONE MOBILISATION VS CONTROL, Outcome 1 Symptoms.
18.2
18.2. Analysis
Comparison 18 CARPAL BONE MOBILISATION VS CONTROL, Outcome 2 Improved pain.
18.3
18.3. Analysis
Comparison 18 CARPAL BONE MOBILISATION VS CONTROL, Outcome 3 Improved hand function.
18.4
18.4. Analysis
Comparison 18 CARPAL BONE MOBILISATION VS CONTROL, Outcome 4 Active wrist flexion (degrees).
18.5
18.5. Analysis
Comparison 18 CARPAL BONE MOBILISATION VS CONTROL, Outcome 5 Active wrist extension (degrees).
18.6
18.6. Analysis
Comparison 18 CARPAL BONE MOBILISATION VS CONTROL, Outcome 6 Improvement in upper limb tension test (ULTT2a).
18.7
18.7. Analysis
Comparison 18 CARPAL BONE MOBILISATION VS CONTROL, Outcome 7 Need for surgical release.
19.1
19.1. Analysis
Comparison 19 NEURODYNAMIC VS CARPAL BONE MOBILISATION, Outcome 1 Symptoms.
19.2
19.2. Analysis
Comparison 19 NEURODYNAMIC VS CARPAL BONE MOBILISATION, Outcome 2 Improved pain.
19.3
19.3. Analysis
Comparison 19 NEURODYNAMIC VS CARPAL BONE MOBILISATION, Outcome 3 Improved hand function.
19.4
19.4. Analysis
Comparison 19 NEURODYNAMIC VS CARPAL BONE MOBILISATION, Outcome 4 Active wrist flexion (degrees).
19.5
19.5. Analysis
Comparison 19 NEURODYNAMIC VS CARPAL BONE MOBILISATION, Outcome 5 Active wrist extension (degrees).
19.6
19.6. Analysis
Comparison 19 NEURODYNAMIC VS CARPAL BONE MOBILISATION, Outcome 6 Improvement in upper limb tension test (ULTT2a).
19.7
19.7. Analysis
Comparison 19 NEURODYNAMIC VS CARPAL BONE MOBILISATION, Outcome 7 Need for surgical release.
20.1
20.1. Analysis
Comparison 20 MAGNET THERAPY VS PLACEBO, Outcome 1 Pain.
21.1
21.1. Analysis
Comparison 21 CHIROPRACTIC VS MEDICAL CARE, Outcome 1 Physical distress.
21.2
21.2. Analysis
Comparison 21 CHIROPRACTIC VS MEDICAL CARE, Outcome 2 Mental distress.
21.3
21.3. Analysis
Comparison 21 CHIROPRACTIC VS MEDICAL CARE, Outcome 3 Vibrometry (db).
21.4
21.4. Analysis
Comparison 21 CHIROPRACTIC VS MEDICAL CARE, Outcome 4 Hand function.
21.5
21.5. Analysis
Comparison 21 CHIROPRACTIC VS MEDICAL CARE, Outcome 5 Health‐related quality of life (SF‐36).
22.1
22.1. Analysis
Comparison 22 LASER ACUPUNCTURE VS PLACEBO, Outcome 1 Improved paresthesia.
22.2
22.2. Analysis
Comparison 22 LASER ACUPUNCTURE VS PLACEBO, Outcome 2 Improved night pain.

References

References to studies included in this review

Aigner 1999 {published data only}
    1. Aigner N, Zoch G, Petje G. Results of laser‐acupuncture in carpal tunnel syndrome: a prospective, randomised and blinded study [Laserakupunktur bei der praoperativen schmerzbekampfung beim karpaltunnelsyndrom: eine prospektiv randomisierte studie]. Deutsche Zeitschrift für Akupunktur 1999;42:70‐5.
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Carter 2002 {published data only}
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Chang 1998 {published data only}
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Ebenbichler 1998 {published data only}
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Garfinkel 1998 {published data only}
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Herskovitz 1995 {published data only}
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Hui 2001 {published data only}
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Ozkul 2001 {published data only}
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Rempel 1999 {published data only}
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Stransky 1989 {published data only}
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Tal‐Akabi 2000 {published data only}
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Tittiranonda 1999 {published data only}
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Walker 2000 {published data only}
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References to studies excluded from this review

Abbot 1999 {published data only}
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Baum 1986 {published data only}
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Bhatia 2000 {published data only}
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Bonebrake 1993 {published data only}
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Finsen 1999 {published data only}
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Girlanda 1993 {published data only}
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Hafner 1999 {published data only}
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Helwig 2000 {published data only}
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Hochberg 2001 {published data only}
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Jarmuzewska 2000 {published data only}
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Kruger 1991 {published data only}
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Li 1999 {published data only}
    1. Li S, Liu L, Miyazaki M, Warren S. Effectiveness of splinting for work‐related carpal tunnel syndrome: a three‐month follow‐up study. Technology and Disability 1999;11(1/2):51.
Lucantoni 1992 {published data only}
    1. Lucantoni C, Grottoli S, Gaetti R. Comparison between He‐Ne laser therapy and steroid injections in the treatment of idiopathic carpal tunnel syndrome [Confronto tra laserterapia He‐Ne e terapia infiltrativa steroidea nel trattamento della sindrome idiopatica del tunnel carpale [Italian]]. La Riabilitazione 1992;25(4):249‐56.
Monge 1995 {published data only}
    1. Monge L, Mattei M, Dani F, Sciarretta A, Carta Q. Effect of treatment with an aldose reductase inhibitor on symptomatic carpal tunnel syndrome in type 2 diabetes. Diabetic Medicine 1995;12:1097‐1101. [MEDLINE: ] - PubMed
Nathan 2001 {published data only}
    1. Nathan PA, Wilcox A, Emerick PS, Meadows KD, McCormack AL. Effects of an aerobic exercise program on median nerve conduction and symptoms associated with carpal tunnel syndrome. Journal of Occupational and Environmental Medicine 2001;43:840‐3. - PubMed
O'Gradaigh 2000 {published data only}
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Ozdogan 1984 {published data only}
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Padua 1999 {published data only}
    1. Padua L, Padua R, Moretti C, Nazzaro M, Tonali P. Clinical outcome and neurophysiological results of low‐power laser irradiation in carpal tunnel syndrome. Lasers in Medical Science 1999;14:196‐202.
Piotrowski 1998 {published data only}
    1. Piotrowski M, Szczepanski L, Dmoszynska M. Treatment of rheumatic conditions with local instillation of betamethasone and methylprednisolone: comparison of efficacy and frequency of irritative pain reaction [Leczenie chorob tkanek miekkich okolostawowych i zapalen stawow iniekcjami octanu metylprednizolonu (depo‐medrol) i betametazonem (diprophos): porownanie skutecznosci i wystepowania miejscowych odczynow bolowych]. Reumatologia 1998;36:78‐84.
Provinciali 2000 {published data only}
    1. Provinciali L, Giattini A, Splendiani G, Logullo F. Usefulness of hand rehabilitation after carpal tunnel surgery. Muscle & Nerve 2000;23:211‐6. [MEDLINE: ] - PubMed
Rozmaryn 1998 {published data only}
    1. Rozmaryn LM, Dovelle S, Rothman ER, Gorman K, Olvey KM, Bartko JJ. Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome. Journal of Hand Therapy 1998;11:171‐9. [MEDLINE: ] - PubMed
Sucher 1994 {published data only}
    1. Sucher BM. Palpatory diagnosis and manipulative management of carpal tunnel syndrome. Journal of the American Osteopathic Association 1994;94(8):647‐63. [MEDLINE: ] - PubMed
Sucher 1999 {published data only}
    1. Sucher BM. Ultrasound therapy effect in carpal tunnel syndrome [letter; comment]. Archives of Physical Medicine & Rehabilitation 1999;80:1117. [MEDLINE: ] - PubMed
Wolaniuk 1983 {published data only}
    1. Wolaniuk A, Vadhanavikit S, Folkers K. Electromyographic data differentiate patients with the carpal tunnel syndrome when double blindly treated with pyridoxine and placebo. Research Communications in Chemical Pathology & Pharmacology 1983;41:501‐11. - PubMed
Wong 2001 {published data only}
    1. Wong SM, Hui ACF, Tang A, Ho PC, Hung LK, Wong KS, Kay R, Li E. Local vs systemic corticosteroids in the treatment of carpal tunnel syndrome. Neurology 2001;56:1565‐7. [MEDLINE: ] - PubMed
Wu 1991 {published data only}
    1. Wu SF, Chan RC, Hsu TC. Electrodiagnostic evaluation of conservative treatment in carpal tunnel syndrome. Chinese Medical Journal 1991;48:125‐30. [MEDLINE: ] - PubMed

References to studies awaiting assessment

Toro 1997 {published data only}
    1. Rioja Toro J, Garcia Rodriguez I, Prada Espinel J, Garcia Caballero M, Arroyo Rodriguez F. Idiopathic carpal tunnel syndrome: efficacy of treatment with iontophoresis‐corticoid versus iontophoresis‐placebo (galvinization) [Sindrome del canal carpiano cronico idiopatico: eficacia del tratamiento de iontoforesis‐corticoide frente a iontoforesis‐placebo (galvanizacion)]. Rehabilitacion 1997;31:118‐26.

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