NON-OPERATIVE TREATMENTS: LONG-TERM

The overall strength was downgraded for this option given the heterogeneity in treatment modalities, study quality, control cohort utilized, and follow-up time periods. One study evaluating oral corticosteroid (Chang 1998). Two studies evaluating hyaluronic acid injection demonstrate limited evidence in favor of hyaluronic acid injection at 6 months as compared to a normal saline injection (Wu 2022) and no difference between a hyaluronic acid and normal saline injection at 1-, 3-, and 6-mo follow up time points (Su 2021).

There are three studies that evaluated the utilization of hydro dissection for the treatment of carpal tunnel syndrome. Elawamy et al.2020 demonstrated improved pain and function 6 months after hydro dissection with Hyalase and 10 mL saline solution injection as compared to hydro dissection with 10mL of saline solution only. We et al.2018 demonstrated that hydro dissection resulted in improved function and symptom severity compared to subcutaneous injection at 6mo. He et al.2022 demonstrated that hydro dissection with 5% dextrose as an add on to a corticosteroid injection resulted in improved patient reported outcome scores at 3 mo.

Five studies evaluated kinesiotaping, two favoring kinesiotaping and three demonstrating no difference as compared to various treatment modalities including an orthosis, placebo kinesiotaping, nerve and tendon gliding exercises (Geler 2016, De Sire 2021, Aminian 2022, Mansiz 2019, Yildririm 2018).

Seven studies evaluated the utilization of laser therapy, four of which were either mixed or favored laser therapy whereas three demonstrated no difference in outcomes when comparing laser therapy to orthosis and/or placebo (Barbosa 2016, Chang 2008, Dincer 2009, Evic 2007, Fusakul 2014, Guner 2018, Yagci 2019). Metin et al.2017 evaluated peloid treatment with nighttime orthosis as compared to nighttime orthosis alone and demonstrated improvements in functionality at one month.

The overall strength was downgraded for this option given the heterogeneity in treatment modalities, study quality, control cohort utilized, and follow-up time periods. One study evaluating oral corticosteroid (Chang 1998). Two studies evaluating hyaluronic acid injection demonstrate limited evidence in favor of hyaluronic acid injection at 6 months as compared to a normal saline injection (Wu 2022) and no difference between a hyaluronic acid and normal saline injection at 1-, 3-, and 6-mo follow up time points (Su 2021).

There are three studies that evaluated the utilization of hydro dissection for the treatment of carpal tunnel syndrome. Elawamy et al.2020 demonstrated improved pain and function 6 months after hydro dissection with Hyalase and 10 mL saline solution injection as compared to hydro dissection with 10mL of saline solution only. We et al.2018 demonstrated that hydro dissection resulted in improved function and symptom severity compared to subcutaneous injection at 6mo. He et al.2022 demonstrated that hydro dissection with 5% dextrose as an add on to a corticosteroid injection resulted in improved patient reported outcome scores at 3 mo.

Five studies evaluated kinesiotaping, two favoring kinesiotaping and three demonstrating no difference as compared to various treatment modalities including an orthosis, placebo kinesiotaping, nerve and tendon gliding exercises (Geler 2016, De Sire 2021, Aminian 2022, Mansiz 2019, Yildririn 2018).

Seven studies evaluated the utilization of laser therapy, four of which were either mixed or favored laser therapy whereas three demonstrated no difference in outcomes when comparing laser therapy to orthosis and/or placebo (Barbosa 2016, Chang 2008, Dincer 2009, Evic 2007, Fusakul 2014, Guner 2018, Yagci 2019). Metin et al.2017 evaluated peloid treatment with nighttime orthosis as compared to nighttime orthosis alone and demonstrated improvements in functionality at one month.

Wu et al.2017, when comparing perineural injection therapy with 5% dextrose to perineural injection therapy with normal saline, demonstrated clinical improvement in the former group at 6 months post injection. Five studies evaluated the use of topical treatments (e.g., lavender oil, chamomile oil) that demonstrated varied results as compared to placebo (Eftekharsadat 2018, Flondell 2017, Hashempur 2015, Karimi 2021, Hashempur 2017.

Ten studies evaluate short term (up to 6-month) effects of shockwave therapy, eight of which demonstrate benefits and two of which demonstrate no difference in outcomes as compared to sham treatment, (Habibzadeh 2022, Kocak 2020, Gesslbauer 2021, Chang 2020, Wu 2016, Vahdatpour 2016, Saglam 2022, Haghighat 2021, Raissi 2017, Karatas 2019). Six studies evaluated exercise therapy or neuromobilization for the treatment of carpal tunnel syndrome. There was great variation in the intervention protocols (Shem 2020, Zidkova 2019, Abdolrazaghi 2021, Hesami 2018, Salehi 2019). Shem 2020 showed symptom improvements after 6 weeks of self-myofascial stretching. Zidkova 2019 showed 9-week improved symptom scores after exercise with neuromobilization techniques. Abdorlrazaghi 2021 found that a 6-week gliding exercise with splinting protocol did not provide improvement in comparison to splinting alone. Hesami 2018 and Salehi similarly showed nerve and gliding tendon exercises provide benefit in comparison to splinting alone after 6-week protocols.

Bahrami (2019) evaluated ozone injection with splinting as compared to splinting alone and demonstrated clinical improvement in the intervention arm. Elbalawy 2020 compared sensory rehabilitation with physical therapy as compared to physical therapy alone for carpal tunnel syndrome and demonstrated no difference in cohorts.

Four studies evaluate various manual therapies for the treatment of carpal tunnel syndrome. Despite various therapy modalities and time periods of follow up, each study favors manual therapy as compared to the control cohort. Jimenez Del Barrio 2018 investigated diacutaneous fibrolysis; Wolny investigated neurodynamic techniques administered twice per week for ten weeks in both 2018 and 2019. Dinarvand 2017 compared hamate and scaphoid mobilization with splinting with splinting alone and found that while both groups improved significantly at ten-week follow-up, the degree of improvement was larger in the mobilization group. Chen 2015 compared ultrasound-guided pulsed radiofrequency treatment with night splinting as compared to night splinting alone and demonstrated improved pain and functional outcome scores in the intervention cohort. Weintraub et al. evaluated the use of static and pulsed electromagnetic fields for the treatment of carpal tunnel and noted improvements in pain as compared to sham treatment.

Benefits/Harms of Implementation
The above interventions do not demonstrate a consistently significant difference as compared to control cohorts. Each treatment is associated with its own time and monetary expense, as well as risk profile.

Cost Effectiveness/Resource Utilization
Given the lack of effectiveness of the above treatments, they are not considered cost effective for the treatment of carpal tunnel syndrome.

Acceptability
Due to lack of supporting evidence, this guideline is anticipated to be accepted by surgeons, patients, and therapists.

Future Research
Future research may include studies that compare non operative treatment options to carpal tunnel release and/or with a more consistently defined intervention and/or control cohort.