Archives of Physical Medicine and Rehabilitation

journal homepage: www.archives-pmr.org

Archives of Physical Medicine and Rehabilitation 2017;-:-------

REVIEW ARTICLE

Carpal Tunnel Syndrome: Effectiveness of Physical

Therapy and Electrophysical Modalities. An Updated
Systematic Review of Randomized Controlled Trials
Bionka M. Huisstede, PhD,a Peter Hoogvliet, MD, PhD,b Thierry P. Franke, MSc, PT,a
Manon S. Randsdorp, MD,b,c Bart W. Koes, PhDc
From the aDepartment of Rehabilitation, Physical Therapy Science & Sports, Brain Center Rudolf Magnus, University Medical Center Utrecht,
Utrecht; bDepartment of Rehabilitation Medicine, Erasmus University Medical Center, Rotterdam; and cDepartment of General Practice,
Erasmus University Medical Center, Rotterdam, The Netherlands.

Abstract
Objective: To review scientific literature studying the effectiveness of physical therapy and electrophysical modalities for carpal tunnel syndrome
(CTS).
Data Sources: The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database.
Study Selection: Two reviewers independently applied the inclusion criteria to select potential eligible studies.
Data Extraction: Two reviewers independently extracted the data and assessed the methodologic quality using the Cochrane Risk of Bias Tool.
Data Synthesis: A best-evidence synthesis was performed to summarize the results of the included studies (2 reviews and 22 randomized
controlled trials [RCTs]). For physical therapy, moderate evidence was found for myofascial massage therapy versus ischemic compression on
latent, or active, trigger points or low-level laser therapy in the short term. For several electrophysical modalities, moderate evidence was found in
the short term (ultrasound vs placebo, ultrasound as single intervention vs other nonsurgical interventions, ultrasound vs corticosteroid injection
plus a neutral wrist splint, local microwave hyperthermia vs placebo, iontophoresis vs phonophoresis, pulsed radiofrequency added to wrist splint,
continuous vs pulsed vs placebo shortwave diathermy, and interferential current vs transcutaneous electrical nerve stimulation vs a night-only
wrist splint). In the midterm, moderate evidence was found in favor of radial extracorporeal shockwave therapy (ESWT) added to a neutral wrist
splint, in favor of ESWT versus ultrasound, or cryo-ultrasound, and in favor of ultrasound versus placebo. For all other interventions studied, only
limited, conflicting, or no evidence was found. No RCTs investigating the long-term effects of physical therapy and electrophysical modalities
were found. Because of heterogeneity in the treatment parameters used in the included RCTs, optimal treatment parameters could not be
identified.
Conclusions: Moderate evidence was found for several physical therapy and electrophysical modalities for CTS in the short term and midterm.
Future studies should concentrate on long-term effects and which treatment parameters of physical therapy and electrophysical modalities are
most effective for CTS.
Archives of Physical Medicine and Rehabilitation 2017;-:-------
ª 2017 by the American Congress of Rehabilitation Medicine

Carpal tunnel syndrome (CTS) is a disorder that decreases the
function of the hand musculature and/or sensibility on the palmar
side of the hand.1 Work-related CTS is one of the most disabling
and costly upper extremity disorders, resulting in lost work days
and consequently represents a major cause of workers’ compen-
sation costs.2
Disclosures: none.
Characteristic complaints of CTS appear in the area innervated
by the median nerve and include pain, paresthesia, and numbness
in the fingers and hand.3 Entrapment neuropathies (eg, CTS) are
theorized to occur because of a combination of compression and
traction on the median nerve.4,5 For example, the fluid pressure in
the carpal tunnel was reported to increase 8 to 10 times the
normative pressure during wrist flexion and extension, respec-
tively, causing ischemic compression on the median nerve.1
Furthermore, the presence of CTS is associated with a daily

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https://doi.org/10.1016/j.apmr.2017.08.482
2 B.M. Huisstede et al
8-hour energy-equivalent frequency-weighted acceleration of
3.9m/s, repetitiveness at work, and an average hand force
requirement of >4kg.6
In clinical practice, many interventions, both nonsurgical and
surgical, are used to manage CTS. Patients with CTS are often
referred to hand therapists.7 The latter often use electrophysical
modalities such as ultrasound, extracorporeal shockwave therapy
(ESWT), and magnetic field therapy. Electrophysical modalities
aim to stimulate tissue healing through various mechanisms which
are not fully known.8-10
The development of mono- and multidisciplinary guidelines is
a continuing process to further optimize the quality of care for
patients with CTS.7,11,12 To support the development of guide-
lines, an overview of evidence for effectiveness of interventions
is required. Therefore, we systematically reviewed scientific
literature to provide an overview of the current state-of-the-art for
the evidence of the effectiveness of interventions to treat CTS.
This article is the second part of a 3-part update of a review
published in 2010.13 These reviews focus on the nonsurgical
treatment of CTS. This review focuses specifically on the
effectiveness of physical therapy and electrophysical modalities
for CTS (except low-level laser therapy [LLT], which is covered
in a separate review14).
Methods
Search strategy
To identify relevant systematic reviews and randomized controlled
trials (RCTs) on CTS, we searched the Cochrane Library,
PubMed, Embase, CINAHL, and Physiotherapy Evidence Data-
base (PEDro) (1) for interventions included in the systematic re-
views from the date of the search strategy of the review up to April
8, 2016 (ie, recent RCTs) and (2) from the beginning of the
database to April 8, 2016 (ie, additional RCTs). Keywords related
to CTS such as carpal tunnel syndrome, median nerve entrapment,
and interventions were included in the literature search. The
complete search strategy is presented in appendix 1.
Inclusion criteria
Only systematic reviews and/or RCTs were considered eligible for
inclusion if they fulfilled all of the following criteria: (1) included
patients with CTS, (2) CTS was not caused by an acute trauma or
any systemic disease as described in the definition of complaints
of the arm, neck and/or shoulder,15 (3) physical therapy or an
electrophysical modality (types of physical therapy that aim to
reduce pain and improve function via an increase in energy
[electrical, sound, light, or thermal] into the body16) for treating
CTS was evaluated, and (4) included measures which reported on
List of abbreviations:
CTS carpal tunnel syndrome
ESWT extracorporeal shockwave therapy
FSS Functional Status Scale
LLT low-level laser therapy
PEDro Physiotherapy Evidence Database
RCT randomized controlled trial
SSS Symptom Severity Scale
TENS transcutaneous electrical nerve stimulation
pain, function, or recovery measured using patient-reported
outcome measures or objective measurements. There were no
language restrictions.
RCTs for which a subset of the total number of patients met the
inclusion criteria were only included if outcomes for the subset of
patients were reported separately.
Study selection
Two reviewers (T.P.F. and S.J.G) independently applied the in-
clusion criteria to select potential relevant reviews and RCTs from
the title and abstracts of the references retrieved by the literature
search. A consensus method was used to solve any disagreements
concerning inclusion of studies, and a third reviewer (B.M.H.) was
consulted if disagreement persisted.
Categorization of the relevant literature
Relevant publications were categorized under 3 headers: system-
atic reviews, recent RCTs, and additional RCTs.13,17-19 The
header systematic reviews describes all Cochrane and Cochrane-
based systematic reviews. The header recent RCTs contains all
RCTs published from the final date of the search strategy covered
by the systematic review. Finally, the header additional RCTs
describes all RCTs concerning interventions that have not yet been
described in a systematic review.
Data extraction
Two researchers (T.P.F. and S.J.G) independently extracted the
data. Information was collected on the study population, in-
terventions used, outcome measures, and outcome. Disagreements
in the data extraction were solved using a consensus method, if
disagreement persisted a third reviewer (B.M.H.) was consulted.
Follow-up periods were categorized as short-term (0 to
3mo),
midterm (4 to
6mo), or long-term (>6mo) effects.
Methodologic quality assessment
To identify potential risks of bias of the included RCTs, 2 re-
viewers (T.P.F. and S.J.G) independently assessed the meth-
odologic quality of each RCT. The 12 quality criteria and
operationalization of these criteria (appendix 2) from Furlan
et al20 were used. Each item was scored as yes, no, or do not
know. High quality was defined as a score of 50% (ie, a yes
score on 50% of the criteria) on this methodologic quality
assessment. A consensus procedure was used to solve any
disagreement between the reviewers, and a third reviewer
(B.M.H.) was consulted if disagreement persisted.
Data synthesis
If quantitative analysis of the studies was not possible because of
diverse outcome measures and other clinical heterogeneity, a
meta-analysis was not performed. Instead, a best-evidence syn-
thesis was used: the results were summarized using a rating sys-
tem consisting of 5 levels of scientific evidence, taking into
account the methodologic quality and the outcome of the original
studies (table 1).21 The level of evidence was determined based on
the number of available RCTs for a certain intervention (ie, the
number of RCTs found in the reviews plus the number of recent
RCTs or the number of additional RCTs). The results of a RCT
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Physical therapy and electrophysical modalities for CTS 3

Table 1 Ranking of the levels of evidence Results

Level of Evidence Description
Strong evidence Consistent (75% of the trials report
consistent findings); positive
(significant) findings within multiple
higher-quality RCTs
Moderate evidence Consistent positive (significant) findings
within multiple lower-quality RCTs
and/or 1 high-quality RCT
Limited evidence Positive (significant) findings within 1
low-quality RCT
Conflicting evidence Conflicting (significant) findings in the
RCTs (<75% of the trials report
consistent findings)
No evidence RCTs available, but no (significant)
differences between intervention and
control groups were reported
No systematic reviews No systematic review or RCT found
or RCTs found
NOTE. Levels of evidence as described by van Tulder et al.21
were only included in the best-evidence synthesis if a between-
group comparison was made (treatment vs another treatment,
placebo, or control) and the level of significance was reported. The
results of the study were labeled as significant if 1 of the 3
outcome measures had significant results.
Characteristics of the included studies
The literature search for systematic reviews identified 563 studies
(Cochrane Library: nZ16, PubMed: nZ263, Embase: nZ224,
CINHAL: nZ27, PEDro: nZ33). Furthermore, the search for
RCTs identified 2681 studies (PubMed: nZ697, Embase: nZ1718,
CINAHL: nZ156, PEDro: nZ110) (fig 1). Finally, after selection
based on the content of the titles, abstracts, and full text, 2 reviews
and 22 RCTs (PubMed: nZ19, Embase: nZ1, CINAHL: nZ2,
PEDro: nZ0) were included. Two references (Embase22,23) were
initially included based on the content of their abstract. Because the
full texts were unavailable in (inter)national medical libraries, we
contacted the authors by e-mail. Nevertheless, full-text versions
remained unavailable and the 2 articles were excluded.22,23 The
data extraction of the included studies is presented in appendix 3
(systematic reviews) and appendix 4 (RCTs).
Methodologic quality of the included studies
The results of the methodologic quality assessment of the 17
RCTs included in the 2 Cochrane reviews9,24 and 22 included
recent RCTs are presented in tables 2 and 3, respectively.
The 2 included Cochrane reviews9,24 used 8 quality criteria
attained from the Cochrane Handbook (version 5.1.0)25 in which
RCTs were defined as high-quality (A), moderate quality (B), or
low quality (C); RCTs of moderate and high quality scored 50%
of these quality criteria. Therefore, A and B were classified as
high-quality RCTs. Consequently, 11 (61%) and 7 (39%) were

Fig 1 Flowchart of the literature search. )Studies identified using the search string for systematic reviews. yStudies identified using the search
string for RCTs.

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 4
Table 2 Methodologic quality assessment of the RCTs included in the systematic reviews
Blinding of Blinding
Allocation Participants Outcome Incomplete Incomplete Selective Our Definition
Random Sequence Concealment and Personnel Assessors Outcome Data Outcome Data Reporting of High or
Generation (Selection (Performance (Detection (Attrition (Attrition (Reporting Other Score Study Low Quality
Systematic Review Reference RCT (Selection Bias) Bias) Bias) Bias) Bias):
3mo Bias): >3mo Bias) Bias* Maximum Score of Study
Page et al9 Ebenbichler et al26 þ þ þ þ ? ?   8 5 High
Therapeutic Bilgici et al27 ? þ  ? þ n/a þ þ 7 4 High
ultrasound Koyuncu et al28 ? ? þ ? þ n/a  ? 7 3 Low
for CTS Oztas et al29 ? ? þ  ? n/a ? þ 7 2 Low
Page et al24 Akalin et al30 ?    þ þ þ þ 8 4 High
Exercise and Bialosky et al31 þ þ þ þ ? n/a þ þ 7 6 High
mobilization Pinar et al32   þ þ þ n/a þ þ 7 5 High
for CTS Tal-Akabi et al33 þ ?  þ þ n/a þ þ 7 5 High
Baysal et al34 þ ?  þ þ  þ þ 8 5 High
Burke et al35 þ ?  þ þ n/a  þ 7 4 High
Moraska et al36 ?  þ  þ n/a þ þ 7 4 High
Bardak et al37 þ ?  þ þ þ  þ 8 4 High
Brininger et al38 ? þ   þ n/a  þ 7 3 Low
Bahrami et al39    ? þ ? ? þ 8 2 Low
Heebner and þ     n/a  þ 7 2 Low
Roddey40
Horng et al41 ? ?  þ ? n/a  þ 7 2 Low
Field et al42 ? ?  ? ? n/a  þ 7 1 Low
Abbreviations: þ, yes;  , no; ?, unsure; n/a, not applicable.
* Other bias refers to, for example, inappropriate unit of analysis.
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B.M. Huisstede et al
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Physical therapy and electrophysical modalities for CTS

Table 3 Methodologic quality scores of the included RCTs
Free of Timing
Incomplete Incomplete Suggestions Compliance of the
Blinding of Outcome Data Outcome of Selective Similarity of Cointerventions Acceptable Outcome
Adequate Allocation Blinding of Blinding of Outcome Addressed? Data? ITT Outcome Baseline Avoided or in All Assessment Score Study
Study Randomization? Concealment? Patients? Caregiver? Assessors? Dropouts? Analysis? Reporting? Characteristics? Similar? Groups? Similar? Maximum Score %
Colbert et al8 þ þ  þ þ þ þ þ þ þ þ þ 12 11 92
Arikan et al43 ? þ þ þ þ þ ? þ þ þ ? þ 12 9 75
Paoloni et al44 þ þ   þ þ þ þ þ þ ? þ 12 9 75
Wu et al45 þ þ þ ? þ þ þ þ þ þ ? þ 12 9 75
Seok and þ ?   þ þ þ þ þ þ n/a þ 11 8 73
Kim46
Amirjani þ þ þ þ þ þ  þ ? ? ? þ 12 8 67
et al47
Bakhtiary þ þ   þ þ þ þ þ ? ? þ 12 8 67
et al48
Hains et al49 þ þ þ  þ þ ? þ þ þ ? ? 12 8 67
Boyacı et al50 þ ? ?  þ þ þ þ þ þ ? þ 12 8 67
Frasca et al51 þ þ þ  þ þ þ ? þ ? ? þ 12 8 67
Raeissadat þ ?   þ þ þ þ þ þ ? þ 12 8 67
et al52
Chen et al53 þ þ   þ   þ þ þ ? þ 12 7 58
Gunay and þ ?   þ þ þ þ  þ ? þ 12 7 58
Alp54
Koca et al55  ?   þ þ þ þ þ ? þ þ 12 7 58
Armagan þ þ þ  þ  ? þ  ? ? þ 12 6 50
et al56
Notarnicola ? ?   ? þ þ þ þ þ ? þ 12 6 50
et al57
Weintraub and þ ? þ ? ? þ  þ ? þ ? þ 12 6 50
Cole58
Gurcay et al59 ? ?    þ þ þ þ ? ? þ 12 5 42
Michlovitz60 ? ?   þ þ þ þ  ? ? þ 12 5 42
Oskouei et al61 ? ? ?  þ þ þ þ ?  ? þ 12 5 42
Pratelli et al62  ?   þ þ ? þ þ ? ?  12 4 33
Madenci  ?   ? ? ? þ þ  ? þ 12 3 25
et al63
Abbreviations: þ, yes; , no; ?, unsure; ITT, intention to treat; n/a, not applicable.

5
6 B.M. Huisstede et al
classified as high- and low-quality RCTs, respectively. Further-
more, of the 22 included recent RCTs, 17 (77%) were classified as
high and 5 (23%) as low quality.
Effectiveness of interventions
The 2 Cochrane reviews,9,24 17 RCTs (nZ730), and 22 recent
RCTs (nZ922) studied the effectiveness of physical therapy and
electrophysical modalities for CTS.
Strong and moderate evidence for the effectiveness of physical
therapy and electrophysical modalities for CTS is presented in
table 4. A complete overview of the evidence found for the
effectiveness of physical therapy and electrophysical modalities to
treat CTS is presented in table 5.
Physical therapy
Tendon and nerve gliding exercises as additive to other
nonsurgical interventions
The Cochrane review of Page et al24 included 7
RCTs29,31,33,36-38,63 investigating tendon and nerve gliding exer-
cises added to other nonsurgical interventions.
Systematic review. One high-quality RCT63 (nZ111) compared (1)
nerve and tendon gliding exercises alone with (2) splint plus steroid
injection plus nerve and tendon gliding exercises or (3) splint plus
steroid injection for 6 weeks. At 6-week follow-up, significantly
greater improvement on the symptom total score and on the Func-
tional Status Scale (FSS) score was reported in favor of group 3
versus group 1. No significant differences between groups 1 and 2
were found.
Three low-quality RCTs29,31,37 (nZ99) studied the effect of
nerve and tendon gliding exercises added to different splinting
regimens. Bahrami et al37 used a night-only wrist brace in 5 of
extension for 4 weeks. Akalin et al29 used a neutral wrist splint for
6 weeks. Pinar et al31 applied a day-and-night splint for 6 weeks to
both groups, and subsequently used a night splint only in both
groups, and continued nerve and tendon gliding exercises in the
experimental group for the remaining 4 weeks. All 3 RCTs found
no significant differences between the groups on pain, function, or
recovery at 4-week,37 10-week,31 or 3-month29 follow-up.
A low-quality RCT38 (nZ60) compared active neurodynamic
exercises added to standard care (consisting of a splint worn at
night and during heavy activities plus tendon gliding exercises).
On the FSS score, significant differences were reported in favor of
the active neurodynamic group at 6-month follow-up (PZ.016).
One high-36 and 1 low-quality33 RCT (nZ107) reported on
nerve and tendon gliding exercises as additive to other nonsurgical
interventions. Brininger et al36 studied 2 types of splints (group 1,
a neutral wrist plus metacarpophalangeal splint; group 2, a wrist
cock-up splint), with and without tendon and nerve gliding exer-
cises (groups 3 and 4, respectively). Baysal et al33 reported on
ultrasound, splinting, and nerve and tendon gliding exercises
(group 1: splint plus nerve and tendon gliding exercises, group 2:
splint plus ultrasound, group 3: splint plus ultrasound plus nerve
and tendon gliding exercises). Both Brininger36 and Baysal33 did
not report between-group results.
Concluding, there is no evidence for the effectiveness of
tendon and nerve gliding exercises as additive to nonsurgical in-
terventions (ie various splinting regimens, splint plus steroid in-
jection, splint plus ultrasound in the short term). For the midterm,
limited evidence was found.
Table 4 Strong and moderate evidence for effectiveness of
physical therapy and electrophysical modalities for CTS
Nonsurgical Interventions
to Treat CTS Strong or Moderate Evidence Found
Physical therapy U*
Electrophysical modalities Uy,z,x,jj,{,#,**,yy,zz,xx
Abbreviation: U, strong or moderate evidence found.
* Moderate evidence in the short term in favor of myofascial massage
therapy versus ischemic compression or LLT at 3-week follow-up.
y
Moderate evidence in the short term in favor of ultrasound vs
placebo at 7-week follow-up.
z
Moderate evidence in the short term in favor of ultrasound vs
corticosteroid injection plus a neutral wrist splint at 8-week follow-up.
x
Moderate evidence in the short term in favor of ESWT plus a neutral
night wrist splint vs placebo ESWT with the same splint at 11-week
follow-up.
jj
Moderate evidence in the short term in favor of local microwave
hyperthermia vs placebo at 4-week follow-up.
{
Moderate evidence in the short term in favor of iontophoresis vs
phonophoresis at 4-week follow-up.
#
Moderate evidence in the short term in favor of pulsed radio-
frequency plus splint vs wrist splint at 12-week follow-up.
** Moderate evidence in the short term in favor of continuous
shortwave diathermy vs pulsed shortwave diathermy vs placebo pulsed
shortwave diathermy at 3-week follow-up.
yy
Moderate evidence in the short term in favor of interferential
current vs TENS vs a night-only splint at 6-week follow-up.
zz
Moderate evidence in the midterm in favor of ESWT plus a neutral
night wrist splint vs placebo ESWT with the same splint at 15-week
follow-up.
xx
Moderate evidence in the midterm in favor of ultrasound vs placebo
at 24-week follow-up.
Tendon gliding exercises versus nerve gliding exercises
Systematic review. A low-quality RCT39 (nZ60), included by
Page et al,24 compared (1) nerve gliding exercises plus splint plus
paraffin therapy versus (2) tendon gliding exercises plus splint
plus paraffin therapy versus (3) splint plus paraffin therapy alone.
All exercises were performed 3 times per day, and paraffin therapy
was performed twice a week for 8 weeks. Significant differences
were found in favor of group 2 compared with group 1 on the
Levine FSS score, and the Disabilities of the Arm, Shoulder and
Hand score from baseline to 2-month follow-up. Further, no sig-
nificant differences were found between the 3 treatment groups on
pain (visual analog scale), Levine SSS score, and World Health
Organization quality of life assessment 2 months after the treat-
ment ended.
Therefore, there is limited evidence that tendon gliding exercises
are more effective than nerve gliding exercises in the short term.
Mobilization and manual therapy
Systematic review. Two RCTs (1 high quality34 and 1 low quality32
[nZ43]), included by Page,24 investigated different mobilization
techniques. Burke et al34 studied the effects of the Graston
instrumentaeassisted soft tissue mobilization plus home exercises
versus manual soft tissue mobilization performed by a clinician
plus home exercises. No significant between-group differences on
pain, range of motion (flexion and extension), grip strength, and
the Boston Carpal Tunnel Questionnaire (consisting of the FSS
and Symptom Severity Scale [SSS] scores) were found at 6-month
follow-up.34 Tal-Akabi and Rushton32 studied carpal bone mobi-
lization versus no treatment. A significant difference on CTS
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Physical therapy and electrophysical modalities for CTS 7

Table 5 Overview of evidence of physical therapy and electrophysical modalities

Physical therapy < Targeted massage vs general < Magnetic field therapy
< Nerve and tendon gliding massage therapy 15- vs 45-mT dosage
exercises alone vs splint plus Short term + Short term NE
steroid injection plus nerve and < Massage plus self-massage vs
tendon gliding exercises vs no treatment Heat wrap therapy
splint plus steroid injection* Short term + < Heat wrap therapy* vs
Short term ++ < Madenci massage therapy oral placebo
< Nerve and tendon gliding Short term NE Short term +
exercises as additive to
(1) Night-only wrist splint in 5 Electrophysical modalities Local microwave
of extension ultrasound hyperthermia
Short term NE < Ultrasound* vs placebo < Local microwave
(2) A neutral wrist splint or as Short term (7wk)  hyperthermia* vs placebo
additive to a day and night splint Midterm ++ Short term (4wk) ++
Short term NE < Ultrasound 1.5 vs
(3) A day-and-night splint for 0.8W/cm2 Iontophoresis
6 wk followed by 4wk with Short term (2wk) NE < Dexamethasone
only a night splint < Ultrasound comparison 1 iontophoresis vs placebo
Short term NE vs 3 MHz iontophoresis
< Active neurodynamic Short term (4wk) NE Short term NE
exercises* as additive to a < Ultrasound* vs corticosteroid Midterm NE
splint worn at night and during injection plus a neutral wrist < Iontophoresis* vs
heavy activities plus tendon splint phonophoresis
gliding exercises Short term ++ Short term ++
Midterm + < Ultrasound vs cryoultrasound
< Tendon gliding exercises* vs ESWT* Polarized polychromatic
vs nerve gliding exercises Short term ++ noncoherent light
Short term + Midterm (15wk) ++ radiation
< Polarized polychromatic
Mobilization and manual ESWT noncoherent light radiation
therapy < Radial ESWT plus a neutral as additive to a splint
< Graston instrumenteassisted night wrist splint* vs placebo Short term NE
soft tissue mobilization plus ESWT with the same splint
home exercises vs manual Short term (11wk) ++ Pulsed radiofrequency
mobilization plus home exercises Midterm (15wk) ++ < Pulsed radiofrequency as
Midterm NE < Radial ESWT* vs a local additive to a wrist splint
< Carpal bone mobilization* vs injection with 1mL of lidocaine Short term ++
no treatment plus a single ultra-sonographic
Short term + injection with 1mL of 40mg Shortwave diathermy
< Carpal bone mobilization as triamcinolone acetonide < Continuous shortwave
additive to a night-only splint Short term NE diathermy* vs pulsed short-
Short term + < Radial ESWT* vs a nutra- wave diathermy vs placebo
< Neurodynamic mobilization ceutical intervention pulsed shortwave diathermy
technique as additive to a Short term NE Short term ++
neutral night splint plus TENS Midterm NE
Short term NE Interferential current
< Myofascial Massage therapy Magnetic field therapy < Interferential current* vs
Short term ++ < Magnetic field therapy vs TENS vs a night-only splint
Midterm NE placebo Short term ++
Short term 
Abbreviations: , conflicting evidence; +, limited evidence; ++, moderate evidence; *, denotes in favor of which intervention the evidence was found;
ESWT, extra-corporeal shockwave therapy; NE, no evidence.

symptoms in favor of the carpal bone mobilization group was
reported at 3-week follow-up.
One high-quality RCT31 (nZ40) reported on a neurodynamic
technique that intended to provide anatomic stress across the median
nerve and combined this technique with splinting for 3 weeks. The
intervention was compared with sham therapy plus a splint for 3
weeks. After 3 weeks of treatment, no significant differences be-
tween the groups were found on pain, the Disabilities of the Arm,
Shoulder and Hand Questionnaire, or grip strength.
Recent RCTs. Two recent RCTs (1 high quality54 [nZ40] and 1
low quality61 [nZ20]) investigated the effects of different mobi-
lization techniques. Gunay and Alp54 reported a significant

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8 B.M. Huisstede et al
improvement on pinch grip strength and on the FSS score in favor
of the group that received carpal bone mobilization as additive to a
night-only splint at 3-month follow-up. The second RCT61 re-
ported that 4 weeks of neuromobilization plus a neutral night
splint plus transcutaneous electrical nerve stimulation (TENS) was
significantly more effective than the same intervention without the
neuromobilization on FSS score (PZ.004) at 4-week follow-up.
Therefore, there is conflicting evidence for mobilization and
manual therapy, specifically carpal bone mobilization and neuro-
mobilization maneuvers, in the short term. No evidence was found
in the midterm.
Massage therapy
One Cochrane review,24 which included 2 RCTs,36,42 and 3 recent
RCTs49,62,63 reporting on massage therapy were included.
Systematic review. Two low-quality RCTs36,42 were included in
the aforementioned review.24 Moraska et al36 (nZ27) reported
significant effects on grip strength in favor of the targeted massage
group in the short term (10-wk follow-up, PZ.04). Field et al42
(nZ16) investigated the effect of 15-minute massage once a
week plus self-massage daily versus no treatment. They found
significant differences in favor of the massage group on CTS
symptoms (ie, pain to the affected region tingling, numbness, loss
of strength, burning), (P<.05), pain (P<.05), and grip strength
(P<.05) after 3 treatment sessions at 4-week follow-up.
Recent RCTs. Two recent RCTs49,62 (1 high quality49 [nZ55] and
1 low quality62 [nZ42]) reported on the effectiveness of myo-
fascial massage techniques. Hains et al49 studied (1) ischemic
compression for trigger points versus (2) a control group that
received ischemic compression on a latent or active trigger point.
Both groups were treated 3 times per week for 5 weeks. Pratelli
et al62 studied manual fascial manipulation once a week for 3
weeks versus a control group that had LLT once a day for 5 days.
The RCTs reported significant effects in favor of the intervention
groups on perceived improvement49 after 3 weeks, and on SSS
score62 (P<.0001), FSS score,62 (P<.0001), and pain62 (P<.0001)
after 12 weeks. Furthermore, Hains49 found no significant
between-group differences at 6-month follow-up.
Another RCT63 (low quality, nZ84) reported the effects of the
Madenci massage therapy technique as add-on therapy to a night
splint plus tendon and nerve gliding exercises at 6-week follow-up.
At 6-week follow-up, significant differences were reported in favor
of the group for which the Madenci massage therapy was added on
in hand grip strength (right hand: PZ.042; left hand: PZ.041), SSS
score (PZ.001), FSS score (PZ.001), patient global assessment
(PZ.001), and physician global assessment (PZ.001).63
Concluding, there is moderate evidence in favor of myofascial
massage therapy, consisting of ischemic compression for trigger
points or manual fascial manipulation versus ischemic compression
on latent or active trigger points or LLT, in the short term. For all
other massage therapy techniques, there is limited evidence
(ie, targeted massage vs general massage protocol, massage plus self-
massage vs no treatment, Madenci massage therapy as additive to a
night splint plus tendon and nerve gliding exercises) in the short term.
No midterm evidence was found for myofascial massage therapy.
Electrophysical modalities
Ultrasound
Four RCTs26-29 included in the review from Page et al9 and 2 recent
RCTs44,56 investigating the effectiveness of ultrasound were found.
Ultrasound versus placebo
Systematic review. An analysis of pooled data performed in the
review of Page9 in which 2 high-quality trials26,29 (nZ63) were
included studying the effect of ultrasound therapy versus placebo
showed no significant effects on symptoms, pain, or function at 2-
week follow-up. However, one of the high-quality trials26 showed
significant symptom improvement after 7 weeks in patients treated
with ultrasound, which was maintained at 6-month follow-up.
Recent RCTs. One high-quality RCT56 (nZ46) investigated the
effects of continuous versus pulsed versus placebo ultrasound. At
3-week follow-up, no significant differences between any of the 3
groups were reported on pain, the SSS score, or the FSS score.
Thus in the short term, there is conflicting evidence for the
effectiveness of ultrasound versus placebo. Further, moderate ev-
idence was found in favor of ultrasound in the midterm.
Ultrasound: comparison of intensities
Systematic review. A high-quality RCT29 (nZ30) investigated 2
intensities of ultrasound (1.5 and 0.8W/cm2) and found no sig-
nificant between-group differences on symptom improvement, or
pain at 2-week follow-up.
Therefore, there is no evidence for the effect for ultrasound with an
intensity of 1.5 versus 0.8W/cm2 in the short term at 2-week follow-up.
Ultrasound: different frequencies compared
Systematic review. One low-quality RCT28 (nZ21) compared 2
different frequencies of ultrasound (1 vs 3MHz) and found no
significant differences on pain and function at 4-week follow-up.
Concluding, there is no evidence for the effectiveness of
1- versus 3-MHz frequency of ultrasound in CTS in the short term
at 4-week follow-up.
Ultrasound, as a single intervention, versus other nonsurgical
interventions
Systematic review. One high-quality RCT28 (nZ34), included by
the review of Page et al,9 investigated a 4-week intervention
program including ultrasound 5 times per week versus a local
corticosteroid injection plus a neutral wrist splint. A significant
difference between the groups was found in favor of the ultra-
sound group on grip strength at 4- and 8-week follow-up.
Recent RCTs. A high-quality RCT44 (nZ25) investigated ultrasound
versus cryo-ultrasound and ultrasound versus ESWT. The ESWT
group had significantly better SSS scores versus the ultrasound and
cryo-ultrasound groups at 3-, 7-, and 15-week follow-up (P<.05).
Therefore, moderate evidence was found for ultrasound (5 times
per week for 4wk) versus a corticosteroid injection plus splint only
at 8 weeks in the short term. Further, there is moderate evidence that
ultrasound and cryo-ultrasound were less effective than ESWT.
ESWT versus other nonsurgical interventions
Recent RCTs. A high-quality RCT45 (nZ34) compared radial
ESWT once a week for 3 weeks plus a neutral night wrist splint
with placebo radial ESWT plus the same splint. Significant dif-
ferences between the treatment groups in favor of the radial
ESWT group were reported on pain at 15-week follow-up
(P<.05), the SSS score at 11-week follow-up (P<.05), and the
FSS score at 15-week follow-up (P<.05). No significant differ-
ences were found on finger pinch strength.
Two RCTs (1 high quality46 [nZ31] and 1 low quality57
[nZ60]) investigated ESWT versus a local injection with 1mL
of lidocaine plus a single ultrasonographic injection with 1mL of
40mg triamcinolone acetonide46 and versus a nutraceutical
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Physical therapy and electrophysical modalities for CTS
intervention (containing Echinacea angustifolia, alpha lipoic acid,
and conjugated linoleic acid plus quercetin),57 respectively. Both
RCTs found no significant differences between the treatment
groups on pain, function, or recovery at 1-month,45,57 2-month,57
3-month,46 4-month,57 or 6-month57 follow-up.
Therefore, there is moderate evidence regarding the effec-
tiveness of radial ESWT compared with placebo ESWT in the
short and midterm at 11- and 15-week follow-up, respectively. No
evidence was found for the effect of ESWT versus a nutraceutical
intervention in the short term, and for ESWT versus a steroid
injection both in the short and midterm.
Magnetic field therapy versus placebo magnetic field therapy
Recent RCTs. Significant differences were reported by Weintraub
and Cole58 (high quality, nZ36) on the Neuropathy Pain Scale
(PZ.04) between simultaneous and time-varying dynamic mag-
netic field stimulation on the wrist and placebo therapy at 2-month
follow-up. In contrast, no significant differences were found on
pain and Patients’ Clinical Global Impression of Change at 2-
month follow-up.
Two high-quality RCTs8,43 (nZ98) investigated static8 or
pulsed43 magnetic field therapy versus a placebo treatment. No
significant differences were found on pain, the SSS score, the FSS
score, or the Patients’ Clinical Global Impression of Change at
6-week,8 7-week,8,43 and 18-week8 follow-up. Colbert et al8 also
found no significant differences on pain, the SSS score, the FSS
score, or Patients’ Clinical Global Impression of Change between
2 dosages (15 and 45mT) of magnetic field therapy.
Concluding, in the short term, there is conflicting evidence for
the effectiveness of dynamic, static, or pulsed magnetic field
therapy versus placebo treatment; in the midterm at 18 weeks
there is no evidence. No evidence was found for 15 versus 45mT
of magnetic field therapy.
Heat wrap therapy
Recent RCTs. A RCT60 (low quality, nZ22) investigated low-level
heat wrap therapy (40 C [104 F]) versus oral placebo with 26
measurement points within a follow-up period of 2 days. Signif-
icant differences in favor of low-level heat wrap therapy were
found on pain at 20 of the 26 measurement points (P
.05), joint
stiffness reduction at 19 of the 26 measurement points (P
.05),
grip strength (PZ.012) and SSS score (P
.001). Significant dif-
ferences were found in favor of heat wrap therapy on the FSS after
3 days, but not at 5 days (PZ.006 and PZ.07, respectively).
There is limited evidence that low-level heat wrap therapy
(40 C [104 F]) is more effective than oral placebo in the short
term (3-d follow-up).
Local microwave hyperthermia versus placebo
Recent RCTs. One high-quality RCT51 (nZ22) studied the effects
of local microwave hyperthermiadeight 20-minute sessions 2
times per weekdversus placebo therapy. Significant change
scores were reported in favor of the intervention group on pain
(PZ.004) and on the Levine Boston Carpal Tunnel Questionnaire
part 1 (PZ.009) at 4-week follow-up.
Concluding, there is moderate evidence for the effectiveness of
local microwave hypothermia versus placebo therapy in the
short term.
Iontophoresis versus placebo
Recent RCTs. One recent RCT of high quality47 reported no sig-
nificant differences on the Levine questionnaire between
www.archives-pmr.org
9
dexamethasone sodium phosphate iontophoresis and a placebo
iontophoresis (with distilled water) at 3- and 6-month follow-up.
Therefore, there is no evidence for dexamethasone iontopho-
resis versus placebo in the short and midterm.
Iontophoresis versus phonophoresis
Recent RCTs. Two RCTs (1 high quality48 [nZ34] and 1 low
quality59 [nZ54]) investigated iontophoresis versus phonophoresis.
Bakhtiary and colleagues48 studied 0.4% dexamethasone sodium
phosphate iontophoresis versus phonophoresis, both received 5
times per week for 2 weeks. Significant differences in favor of the
phonophoresis group were reported on pain, pinch strength, and
hand grip strength at 2- and 4-week follow-up.48 Gurcay et al59
studied 0.1% betamethasone iontophoresis plus a night-only wrist
split versus phonophoresis plus the same splint. Gurcay59 reported
significant differences in favor of the phonophoresis group versus
the iontophoresis on SSS score at 3-month follow-up.
Therefore, there is moderate evidence in favor of phonopho-
resis versus 0.4% dexamethasone sodium phosphate or 0.1%
betamethasone iontophoresis in the short term.
Polarized polychromatic noncoherent light as additive to a
splint
Recent RCTs. A high-quality RCT52 (nZ50) investigated the ef-
fects of polarized polychromatic noncoherent light (8 sessions, 3
times per week) added to a neutral wrist splint, worn for 8 weeks.
At 8-week follow-up, no significant differences between the
groups were found on pain. No between-groups statistical tests
were reported on disease severity.
In conclusion, there is no evidence for polarized polychromatic
noncoherent light as additive to a neutral wrist splint in the
short term.
Pulsed radiofrequency as additive to a wrist splint
Recent RCTs. One high-quality RCT53 (nZ44) investigated the
effects of 1 ultrasound-guided pulsed radiofrequency session added
to a wrist splint that was worn for 12 weeks. At 12-week follow-up,
significant differences in favor of the pulsed radiofrequency group
were observed on pain (P<.001), SSS score (P<.001), and FSS score
(PZ.001), but not on finger pinch strength. They also reported a
significant difference in median onset time (measured in number of
days) of pain relief in favor of the pulsed radiofrequency group
(P<.001) using a Kaplan-Meier survival analysis.
Therefore, there is moderate evidence for 1 session of
ultrasound-guided pulsed radiofrequency added to a splinting
regimen in the short term.
Shortwave diathermy
Recent RCTs. One high-quality RCT50 (nZ30) studied the effects of
(1) pulsed versus (2) continuous versus (3) placebo shortwave
diathermy treatment (all groups received 20-min sessions 5 times per
week for 3wk). There were significant differences in favor of group 2
compared with groups 1 or 3 on SSS change scores (PZ.031) at
3-week follow-up. No significant between-group differences were
found on pain (visual analog scale) or FSS score at 3-week follow-up.
Therefore, there is moderate evidence that continuous short-
wave diathermy is more effective than pulsed shortwave
diathermy or placebo shortwave diathermy in the short term.
Interferential current versus TENS versus splinting
Recent RCTs. One high-quality RCT55 (nZ75) investigated a
neutral night splint versus 15 sessions of TENS or 15 sessions of
10
interferential current therapy in a 3-week period. Interferential
current was found to be significantly more effective than a
splinting regimen on pain (P<.01) at 6-week follow-up. Compared
with TENS, interferential current was also significantly more
effective on pain (P<.01), the SSS score (P<.05), and the FSS
score (P<.05) at 6-week follow-up.
Therefore, there is moderate evidence that interferential current
therapy is more effective than a night splint or TENS in the short term.
Discussion
The aim of this systematic review was to present an overview of the
effectiveness of physical therapy and electrophysical modalities for
the management of CTS. Moderate evidence was found for physical
therapies (eg, myofascial massage therapy vs ischemic compression
on latent or active trigger points, LLLT) in the short term. Further,
moderate evidence was found for several electrophysical modalities
in the short-term (ultrasound vs placebo, ultrasound vs a cortico-
steroid injection plus a wrist splint, ESWT plus a neutral night wrist
splint vs placebo ESWT with the same splint, interferential current
vs TENS or a night-only splint, iontophoresis vs phonophoresis at
4wk, continuous shortwave diathermy vs pulsed shortwave
diathermy or placebo pulsed shortwave diathermy) and in the
midterm (ultrasound vs placebo, ESWT plus a neutral night wrist
splint vs placebo ESWT with the same splint). Moreover, no studies
reported on the long-term effectiveness of the interventions. How-
ever, even though moderate evidence was found for all of the
aforementioned interventions, further research is needed to deter-
mine optimal treatment parameters for CTS.
No strong or moderate evidence for physical therapy was
found in the previous version of this review.13 In the previous
version of this review, we found moderate evidence for the
effectiveness of ultrasound and dynamic magnetic field therapy
both versus placebo in the short term.13 However, in this review,
only limited evidence for these treatments was found.
Ultrasound has a long history of use in clinical practice by
physical therapists.64 When using ultrasound, it is assumed that the
temperature in the deep tissue increases through an increase in blood
flow, metabolism, and nerve function.65-67 Temperature can influ-
ence nerve generation.68 Watson64 stated that the clinical outcome
of ultrasound appears to be dose-dependent. However, currently, we
found no evidence for this statement. Our findings are similar to the
results from Page et al,9 who reported no evidence for one ultra-
sound regimen being superior over another. Moreover, the included
RCTs on the effect of different ultrasound intensities or frequencies
only reported results at 2- and 4-week follow-up, respectively.
Therefore, more RCTs are needed to investigate the dose-response
relation of ultrasound in the short, mid-, and long term to treat CTS.
Massage therapy appears promising (moderate evidence) in the
short term. Our findings differ from the results from Page et al,24
who reported limited and low-quality evidence for massage ther-
apy. Within the included RCTs, several massage therapy tech-
niques were used. Some of these techniques could potentially be
more effective than others. Subsequently, additional studies are
needed to determine which massage therapy techniques and
treatment parameters have a positive effect on CTS. Furthermore,
a possible explanation for the difference in results between this
systematic review and the Cochrane review of Page et al24 might
be that this review included multiple recent RCTs on massage
therapy. These recent RCTs were published after the search dates
of the Cochrane review and are now taken into account in the best-
evidence synthesis of this review.
B.M. Huisstede et al
Moderate evidence was found for the effectiveness of several
electrophysical modalities versus other types of physical therapy,
or electrophysical modalities added to other interventions in the
short term. However, these results were all based on a single high-
quality RCT per comparison. Therefore, more research is needed
to confirm these findings and to explore the effect of these treat-
ment in the midterm and long term.
Study limitations
This review has several limitations. The RCTs included in this
systematic review were assessed using multiple quality assessment
tools. The RCTs included in the Cochrane reviews were assessed
for methodologic quality using different versions of the Cochrane
Handbook. For the recent RCTs we used the quality criteria as
described by Furlan et al.20 It is unknown if this methodology
influenced the outcomes of this review. Nonetheless, using mul-
tiple quality assessment tools, 70% of the included RCTs were of
high quality (ie, 50% of the criteria). A methodologic study
concluded that there is empirical evidence that a threshold of
<50% of the criteria is associated with bias.69
Furthermore, this systematic review identified moderate and
strong evidence for several electrophysical modalities. However,
when using these electrophysical modalities, it is important to use
treatment parameters which provide the greatest effect on pain,
function, or recovery. Because of the heterogeneity between the
included RCTs, we were unable to draw any firm conclusions
regarding the optimal treatment parameters for CTS. Therefore,
the results of this review should be interpreted with caution.
Conclusions
Myofascial massage therapy, ultrasound, ESWT, interferential
current, iontophoresis, and continuous shortwave diathermy can
help to reduce pain and symptoms or improve function in CTS in
the short and midterm. However, most studies concentrated on
short-term effects, and only a few studies investigated midterm
effects. No conclusion regarding the optimal dosages and treat-
ment parameters could be drawn. Therefore, more high-quality
studies are needed that investigate which treatment parameters of
physical therapy and electrophysical modalities are most effective.
Further, more studies are needed investigating the long-term ef-
fects of these interventions for patients with CTS.
Supplier
a. Graston instrument; Graston Technique, Indianapolis, IN.
Keywords
Carpal tunnel syndrome; Physical therapy modalities;
Rehabilitation; Review [publication type]; Treatment outcome
Corresponding author
Bionka M. Huisstede, PhD, Rehabilitation, Physical Therapy
Science & Sports, University Medical Center Utrecht, Room,
Building W01.121, PO Box 85500, 3508 GA Utrecht, The
Netherlands. E-mail address: b.m.a.huisstede@umcutrecht.nl.
www.archives-pmr.org
Physical therapy and electrophysical modalities for CTS
Acknowlegment
The authors would like to acknowledge Sven Geelen MSc (S.J.G.)
for his contribution to the literature search, methodological quality
assessment, and data extraction.
Appendix 1 Search String Per Database
PubMed
1. CTS: (("Carpal tunnel syndrome"[mh] OR ("median ner-
ve"[mh] AND (compress* OR entrapment)) OR "carpal tunnel"
OR ((median* AND (nervus OR nerve)) AND (compress* OR
entrapment))))
2. Systematic reviews: (systematic review [ti] OR meta-analysis [pt]
OR meta-analysis [ti] OR systematic literature review [ti] OR this
systematic review [tw] OR (systematic review [tiab] AND review
[pt]) OR meta synthesis [ti] OR meta synthesis [ti] OR integrative
review [tw] OR integrative research review [tw] OR rapid review
[tw] OR consensus development conference [pt] OR practice
guideline [pt] OR cochrane database syst rev [ta] OR acp journal
club [ta] OR health technol assess [ta] OR evid rep technol assess
summ [ta] OR drug class reviews [ti]) OR (clinical guideline [tw]
AND management [tw]) OR((evidence based[ti] OR evidence-
based medicine [mh] OR best practice* [ti] OR evidence synthe-
sis [tiab]) AND (review [pt] OR diseases category[mh] OR
behavior and behavior mechanisms [mh] OR therapeutics [mh] OR
evaluation studies[pt] OR validation studies[pt] OR guideline [pt]
OR pmcbook)) OR ((systematic [tw] OR systematically [tw] OR
critical [tiab] OR (study selection [tw]) OR (predetermined [tw] OR
inclusion [tw] AND criteri* [tw]) OR exclusion criteri* [tw] OR
main outcome measures [tw] OR standard of care [tw] OR stan-
dards of care [tw]) AND (survey [tiab] OR surveys [tiab] OR
overview* [tw] OR review [tiab] OR reviews [tiab] OR search*
[tw] OR handsearch [tw] OR analysis [ti] OR critique [tiab] OR
appraisal [tw] OR (reduction [tw]AND (risk [mh] OR risk [tw])
AND (death OR recurrence))) AND (literature [tiab] OR articles
[tiab] OR publications [tiab] OR publication [tiab] OR bibliog-
raphy [tiab] OR bibliographies [tiab] OR published [tiab] OR
Appendix 2 Methodologic quality criteria: sources of risk of bias
Item
1. Was the method of randomization adequate?
2. Was the treatment allocation concealed?
Was knowledge of the allocated interventions adequately prevented during the study?
3. Was the patient blinded to the intervention?
4. Was the care provider blinded to the intervention?
5. Was the outcome assessor blinded to the intervention?
Were incomplete outcome data adequately addressed?
6. Was the dropout rate described and acceptable?
7. Were all randomized participants analyzed in the group to which they were allocated?
8. Are reports of the study free of suggestion of selective outcome reporting?
Other sources of potential bias:
9. Were the groups similar at baseline regarding the most important prognostic indicators?
10. Were cointerventions avoided or similar?
11. Was the compliance acceptable in all groups?
12. Was the timing of the outcome assessment similar in all groups?
NOTE. Quality criteria and their operationalizations were adapted from Furlan et al.20 High quality was defined as a score of 50% (ie, a yes score on
50% of the criteria) on the methodologic quality assessment.
www.archives-pmr.org
11
unpublished [tw] OR citation [tw] OR citations [tw] OR database
[tiab] OR internet [tiab] OR textbooks [tiab] OR references [tw] OR
scales [tw] OR papers [tw] OR datasets [tw] OR trials [tiab] OR
meta-analy* [tw] OR (clinical [tiab] AND studies [tiab]) OR
treatment outcome [mh] OR treatment outcome [tw] OR
pmcbook)) NOT (letter [pt] OR newspaper article [pt])
3. RCTs: (randomized controlled trial[pt] OR controlled clinical
trial[pt] OR randomized[tiab] OR placebo[tiab] OR clinical
trials as topic[mesh:noexp] OR randomly[tiab] OR trial[ti]
NOT (animals[mh] NOT humans[mh]))
Embase
1. CTS: ‘carpal tunnel syndrome’/de OR (’median nerve’/de AND
‘nerve compression’/de) OR (‘median nerve’/de AND (compress*
OR entrapment):ti,ab) OR ‘carpal tunnel’ OR ((median* AND
(nervus OR nerve)) AND (compress* OR entrapment))
2. Systematic reviews: Filter SR and MA
3. RCTs: random* OR factorial* OR crossover* OR (cross
NEXT/1 over*) OR placebo* OR (doubl* NEXT/1 blind*) OR
(singl* NEXT/1 blind*) OR assign* OR allocate* OR volun-
teer* OR ‘crossover procedure’/exp OR ‘double blind pro-
cedure’/exp OR ‘randomized controlled trial’/exp OR ‘single
blind procedure’/exp OR ‘controlled clinical trial’/exp
PEDro
1. CTS: Carpal tunnel syndrome
CINAHL
1. CTS: (MH “Carpal tunnel syndrome”) or ((MH “median
nerve”) and (compress* or entrapment)) or “carpal tunnel” or
((median* and nerv*) and (compress* or entrapment))
2. Systematic reviews: (MH “Systematic Review”)
3. RCTs: (MH “Clinical Trialsþ”)
Judgment
Yes/No/Unsure
Yes/No/Unsure
Yes/No/Unsure
Yes/No/Unsure
Yes/No/Unsure
Yes/No/Unsure
Yes/No/Unsure
Yes/No/Unsure
Yes/No/Unsure
Yes/No/Unsure
Yes/No/Unsure
Yes/No/Unsure
 12
Appendix 3 Data extraction systematic reviews
No. of
Study Patients Treatment Placebo Control/Comparison Outcome Measures Effect Size
Page et al 201224 563 Neurodynamic X Overall improvement 3wk RR, 15.00; 95% CI, 1.02 to
mobilization 220.92
In favor of neurodynamic
mobilization
Exercise and Pain (VAS) 3wk MD, .57; 95% CI, 1.73 to
mobilization 0.59
interventions Hand function 3wk RR, 9.00; 95% CI, 0.59 to
for CTS (13 137.65
RCTs)30-42 Carpal bone X Overall improvement 3wk RR, 15.00; 95% CI, 1.02 to
mobilization 220.92
In favor of carpal bone
mobilization
Pain (VAS) 3wk MD, 1.43; 95% CI, 2.19 to
0.67
In favor of carpal bone
mobilization
Hand function 3wk RR, 11.00; 95% CI, 0.74 to
163.49
Neurodynamic Carpal bone Overall improvement 3wk RR, 1.00; 95% CI, 0.78 to 1.29
mobilization mobilization Pain (VAS) 3wk MD, 0.86; 95% CI, 0.32 to
2.04
Hand function 3wk RR, 0.80; 95% CI, 0.41 to 1.56
Instrument-assisted Standard soft tissue Overall improvement 3mo RR, 1.24; 95% CI, 0.89 to 1.75
soft tissue mobilization Pain (VAS) Immediately after 6e8wk of
mobilization treatment MD, 5.60; 95% CI,
19.68 to 8.48
3mo after end of treatment MD,
24.50; 95% CI, 43.43 to
5.57
Symptoms (Levine) 3mo after end of treatment MD,
.40; 95% CI, .90 to .10
Functional ability (Levine) 3mo after end of treatment MD,
.10; 95% CI, .69 to .49
Grip strength 3mo after end of treatment MD,
www.archives-pmr.org

0.50; 95% CI, 5.35 to 6.35

Pinch grip strength
opposition
Pinch strength key
B.M. Huisstede et al
3mo after end of treatment MD,
0.40; 95% CI, 0.74 to 1.54
3mo after end of treatment MD,
0.60; 95% CI, 0.47 to 1.67
(continued on next page)
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Physical therapy and electrophysical modalities for CTS

Appendix 3 (continued )
No. of
Study Patients Treatment Placebo Control/Comparison Outcome Measures Effect Size
Targeted CTS soft General soft tissue Symptoms (Levine) At 10wk (4wk of follow-up) MD,
tissue massage massage 1.41; 95% CI, 4.09 to 1.27
Functional ability (Levine) At 10wk (4wk of follow-up) MD,
1.69; 95% CI, 3.74 to 0.36
Isometric grip strength 2d after seventh massage session
(4wk) MD, 2.94; 95% CI, 1.03 to
4.85
Targeted massage is favored.
At 10-wk MD, 3.14; 95% CI, 0.57
to 5.71
Targeted massage is favored.
Isometric pinch strength 2d after seventh massage session
(4wk) MD, 0.90; 95% CI, 0.05 to
1.75
Targeted massage is favored.
2d after eleventh massage session
(6wk) MD, 1.02; 95% CI, 0.18 to
1.86
Targeted massage is favored.
At 10wk (4wk of follow-up) MD,
0.75; 95% CI, 0.13 to 1.63
Functional ability (Grooved At 10wk (4wk of follow-up) MD,
Pegboard Test) 1.31; 95% CI, 9.95 to 7.33
Nerve and tendon Splint Symptoms (Levine) Short-term MD, 0.0; 95% CI, 0.0 to
gliding exercises 0.0
plus splint Functional ability (Levine) Short-term MD, 0.0; 95% CI, 0.0 to
0.0
Grip strength Short-term MD, 2.30; 95% CI,
2.49 to 7.09
Pinch strength Short-term MD, 2.39; 95% CI,
0.43 to 5.21
Symptom improvement Long-term MD, 0.0; 95% CI, 0.0 to
satisfaction 0.0
Nerve and tendon Splint plus steroid Symptom improvement Short-term MD, 2.31; 95% CI, 1.59
gliding exercises injection to 3.03
Favors splint plus steroid
injection.
Functional status score Short-term MD, 4.20; 95% CI, 1.88
to 6.52
(continued on next page)

13

Appendix 3 (continued )
No. of
Study Patients Treatment Placebo
Nerve and tendon
gliding exercises
plus splint plus
steroid injection
Nerve and tendon
gliding exercises
plus therapeutic
ultrasound plus
splint
Nerve and tendon
gliding exercises
plus splint
www.archives-pmr.org
Control/Comparison Outcome Measures
Patient satisfaction
Splint plus steroid Symptom improvement
injection
Functional status score
Patient satisfaction
Therapeutic Pain (VAS)
ultrasound plus
splint Symptoms (Levine)
Functional ability (Levine)
Hand grip strength
Pinch strength
Symptom improvement
Therapeutic Pain (VAS)
ultrasound plus
splint Symptoms (Levine)
Functional ability (Levine)
Hand grip strength
Pinch strength
Symptom improvement
14
Effect Size
Favors splint plus steroid
injection.
Long-term RR, 0.66; 95% CI, 0.45
to 0.98
Favors splint plus steroid
injection.
Short-term MD, 0.50; 95% CI,
1.29 to 0.29
Short-term MD, 0.20; 95% CI,
1.94 to 1.54
Long-term RR, 0.98; 95% CI, 0.74
to 1.29
At 11wk MD, 1.70; 95% CI, 0.26 to
3.14
At 11wk MD, 3.50; 95% CI, 1.65
to 8.65
At 11wk MD, 3.50; 95% CI, 1.08
to 8.08
At 11wk MD, 1.20; 95% CI, 1.60
to 4.00
At 11wk MD, 1.30; 95% CI,
2.86 to 0.26
At 11wk RR, 0.41; 95% CI, 0.14 to
1.18
At 11wk MD, 0.10; 95% CI,
1.87 to 1.67
At 11wk MD, 1.10; 95% CI,
7.31 to 5.11
At 11wk MD, 1.20; 95% CI, 3.80
to 6.21
At 11wk MD, 0.80; 95% CI, 2.42
to 4.02
At 11wk MD, 0.60; 95% CI,
1.92 to 0.72
At 11wk RR, 9.69; 95% CI, 0.55 to
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171.98
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Appendix 3 (continued )
No. of
Study Patients Treatment Placebo Control/Comparison Outcome Measures Effect Size
Neurodynamic Sham neurodynamic Pain (NRS) At the end of 3wk of treatment MD,
technique plus technique plus 3.20; 95% CI, 21.09 to
splint splint 14.69
Clinical pain (MVAS) At the end of 3wk of treatment MD,
3.00; 95% CI, 7.22 to 13.22
Functional ability (DASH At the end of 3wk of treatment MD,
questionnaire) 5.30; 95% CI, 17.49 to 6.89
Grip strength At the end of 3wk of treatment MD,
1.80; 95% CI, 8.68 to 5.08
Nerve and tendon Tendon gliding Levine symptom severity After 1mo of treatment MD, 0.00;
gliding exercises exercises plus score 95% CI, 0.69 to 0.69
plus splint plus splint plus Levine functional status After 1mo of treatment MD, 0.00;
education education score 95% CI, 0.77 to 0.77
DASH score After 1mo of treatment MD, 3.10;
95% CI, 13.34 to 19.54
Nerve and tendon Splint plus paraffin Pain (VAS) Change from baseline to 2mo
gliding exercises therapy posttreatment MD, 6.70; 95% CI,
plus splint plus 8.48 to 21.88
paraffin therapy Levine symptom status Change from baseline to 2mo
score posttreatment MD, 0.30; 95% CI,
0.10 to 0.70
Levine functional status Change from baseline to 2mo
score posttreatment MD, .30; 95% CI,
.11 to .71
DASH score Change from baseline to 2mo
posttreatment MD, 5.40; 95% CI,
3.23 to 14.03
WHOQOLF physical domain Change from baseline to 2mo
score posttreatment MD, 0.77; 95%
CI, 2.01 to 0.47
WHOQOLF psychological Change from baseline to 2mo
domain score posttreatment MD, 0.70; 95% CI,
0.46 to 1.86
WHOQOLF social domain Change from baseline to 2mo
score posttreatment MD, 0.10; 95% CI,
0.96 to 1.16
WHOQOLF environmental Change from baseline to 2mo
domain score posttreatment MD, 0.00; 95% CI,
0.83 to 0.83
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Appendix 3 (continued )
No. of
Study Patients Treatment Placebo Control/Comparison Outcome Measures Effect Size
Nerve gliding Tendon gliding Pain (VAS) Change from baseline to 2mo
exercises plus exercises plus posttreatment MD, 9.20; 95% CI,
splint plus paraffin splint plus paraffin 4.75 to 23.15
therapy therapy Levine symptom status Change from baseline to 2mo
score posttreatment MD, .40; 95% CI,
.06 to .86
Levine functional status Change from baseline to 2mo
score posttreatment MD, .50; 95% CI,
.18 to .82
DASH score Change from baseline to 2mo
posttreatment MD, 8.60; 95% CI,
2.50 to 14.70
In favor of tendon gliding
exercises plus splint plus
paraffin therapy.
WHOQOLF physical domain Change from baseline to 2mo
score posttreatment MD, 0.67; 95%
CI, 1.61 to 0.27
WHOQOLF psychological Change from baseline to 2mo
domain score posttreatment MD, 0.30; 95%
CI, 0.73 to 1.33
WHOQOLF social domain Change from baseline to 2mo
score posttreatment MD, 0.00; 95%
CI, 0.98 to 0.98
WHOQOLF environmental Change from baseline to 2mo
domain score posttreatment MD, 0.00; 95%
CI, 1.07 to 1.07
Tendon gliding Splint plus paraffin Pain (VAS) Change from baseline to 2mo
exercises plus therapy posttreatment MD, 2.50; 95%
splint plus paraffin CI, 19.65 to 14.65
therapy Levine symptom status Change from baseline to 2mo
score posttreatment MD, 0.10; 95%
CI, 0.57 to 0.37
Levine functional status Change from baseline to 2mo
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posttreatment MD, 0.20; 95%

B.M. Huisstede et al
score
CI, 0.61 to 0.21
DASH score Change from baseline to 2mo
posttreatment MD, 3.20; 95%
CI, 12.78 to 6.38
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Physical therapy and electrophysical modalities for CTS

Appendix 3 (continued )
No. of
Study Patients Treatment Placebo Control/Comparison Outcome Measures Effect Size
WHOQOLF physical domain Change from baseline to 2mo
score posttreatment MD, 0.10; 95%
CI, 1.23 to 1.03
WHOQOLF psychological Change from baseline to 2mo
domain score posttreatment MD, 0.40; 95% CI,
0.95 to 1.75
WHOQOLF social domain Change from baseline to 2mo
score posttreatment MD, .10; 95%
CI, .78 to .98
WHOQOLF environmental Change from baseline to 2mo
domain score posttreatment MD, 0.00; 95% CI,
0.97 to 0.97
Nerve gliding Splint plus activity Pain (VAS) At end of 10wk of treatment MD,
exercises plus modification 0.60; 95% CI, 1.74 to 0.54
splint plus activity Grip strength Short-term improvement MD, 0.30;
modification 95% CI, 3.41 to 4.01
Pinch strength Short-term improvement MD, 0.50;
95% CI, 0.47 to 1.47
Page et al. 20139 121 Therapeutic X Overall improvement 7wk, at the end of treatment, RR,
ultrasound 2.36; 95% CI, 1.40 to 3.98
In favor of ultrasound.
Therapeutic Symptom improvement 7wk, at the end of treatment, RR,
ultrasound for 1.77; 95% CI, 1.09 to 2.88
CTS (4 In favor of ultrasound.
RCTs)26-29 Pain (VAS) 1.5W/cm2 after 2wk MD, 1.10;
95% CI, 2.92 to 0.72
0.8W/cm2 after 2wk MD, 0.40;
95% CI, 2.30 to 1.50
Nocturnal waking 1.5W/cm2 after 2wk MD, 0.00; 95%
CI, 0.92 to 0.92
0.8W/cm2 after 2wk MD, 0.40;
95% CI, 1.36 to 0.56
Hand grip strength Change from baseline to 7wk MD,
3.96; 95% CI, 1.31 to 6.61
In favor of ultrasound.
At 7mo 3wk MD, 4.16; 95% CI,
0.88 to 9.20
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Appendix 3 (continued )
No. of
Study Patients Treatment Placebo Control/Comparison Outcome Measures Effect Size
Pinch strength Change from baseline to 2wk MD,
0.19; 95% CI, 0.05 to 0.33
In favor of placebo.
Change from baseline to 7wk MD,
.27; 95% CI, .09 to .63
At 7mo 3wk MD, 0.74; 95% CI,
0.17 to 1.65
Self-reported symptom At 7mo 3wk RR, 1.91; 95% CI, 1.13
improvement (not to 3.23
unsatisfactory outcome) In favor of ultrasound.
Self-reported symptom At 7-mo 3-wk RR, 3.67; 95% CI,
improvement (complete 1.74 to 7.74
remission) In favor of ultrasound.
Therapeutic Therapeutic Pain After 4wk of treatment RR, 0.63;
ultrasound 1MHz ultrasound 3MHz 95% CI, 0.26 to 1.52
Paresthesia After 4wk of treatment RR, 0.37;
95% CI, 0.09 to 1.42
Therapeutic Therapeutic Pain (VAS) After 2wk 5d of treatment MD,
ultrasound ultrasound 0.70; 95% CI, 2.28 to 0.88
1.5W/cm2 0.8W/cm2 Night pain/paresthesia After 2wk 5d of treatment MD,
.30; 95% CI, .90 to .30
Nocturnal waking After 2wk 5d of treatment MD,
0.40; 95% CI, 0.41 to 1.21
Therapeutic Local corticosteroid Symptom severity score 8-wk follow-up MD, .18; 95% CI,
ultrasound injection plus .45 to .81
splint Pain (VAS) 8-wk follow-up MD, 0.12; 95%
CI, 1.39 to 1.15
Functional status score 8-wk follow-up MD, 0.24; 95%
CI, 1.01 to 0.53
Grip strength At the end of 4wk of treatment MD,
2.80; 95% CI, 1.01 to 4.59
In favor of ultrasound.
8-wk follow-up MD, 3.43; 95% CI,
1.71 to 5.15
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Appendix 3 (continued )
No. of
Study Patients Treatment Placebo Control/Comparison Outcome Measures Effect Size
In favor of ultrasound.
Therapeutic Dexamethasone BCTQ symptom severity 3mo posttreatment MD, 5.20; 95%
ultrasound plus iontophoresis plus score CI, 0.27 to 10.13
nerve and tendon nerve and tendon Favors dexamethasone
gliding exercises gliding exercises iontophoresis plus nerve and
plus night splint plus night splint tendon gliding exercises plus
plus activity plus activity night splint plus activity
modification modification modification.
Pain on movement (VAS) Change from baseline to end of
treatment (short term) MD,
1.45; 95% CI, 2.55 to 0.35
Favors dexamethasone
iontophoresis plus nerve and
tendon gliding exercises plus
night splint plus activity
modification.
Pain at rest (VAS) Change from baseline to end of
treatment (short term) MD,
1.35; 95% CI, 2.43 to 0.27
Favors dexamethasone
iontophoresis plus nerve and
tendon gliding exercises plus
night splint plus activity
modification.
Pain at night (VAS) Change from baseline to end of
treatment (short term) MD,
0.10; 95% CI, 1.49 to 1.29
BCTQ functional status 3mo posttreatment MD, 3.50; 95%
score CI, 0.53 to 7.53
Health assessment 3mo posttreatment MD, .07; 95%
questionnaire CI, .26 to .40
Therapeutic Placebo BCTQ symptom severity 3mo posttreatment MD, 1.10;
ultrasound plus iontophoresis plus score 95% CI, 7.11 to 4.91
nerve and tendon nerve and tendon Pain on movement (VAS) Change from baseline to end of
gliding exercises gliding exercises treatment (short term) MD,
plus night splint plus night splint 0.64; 95% CI, 0.32 to 1.60
plus activity plus activity Pain at rest (VAS) Change from baseline to end of
modification modification treatment (short term) MD,
0.70; 95% CI, 0.14 to 1.54

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Appendix 3 (continued )
No. of
Study Patients Treatment Placebo Control/Comparison Outcome Measures Effect Size
Pain at night (VAS) Change from baseline to end of
treatment (short term) MD,
0.64; 95% CI, 0.67 to 1.95
BCTQ functional status 3mo posttreatment MD, 1.85; 95%
score CI, 2.74 to 6.44
Health assessment 3mo posttreatment MD, .02; 95%
questionnaire CI, .36 to .32
Therapeutic Placebo ultrasound Symptom severity score After 2wk of treatment MD, 6.40;
ultrasound plus plus splint 95% CI, 8.40 to 4.40
splint In favor of therapeutic ultrasound
plus splint.
Functional status score After 2wk of treatment MD, 1.00;
95% CI, 4.45 to 2.45
Grip strength After 2wk of treatment MD, .04;
95% CI, .02 to .10
Therapeutic Sham ultrasound Pain/paresthesia Short-term change from baseline
ultrasound plus plus NSAID scores MD, 0.00; 95% CI, 0.66
placebo to 0.66
Frequency of waking Short-term MD, 0.34; 95% CI,
1.12 to 0.44
Pain (VAS) Short-term MD, 0.81; 95% CI,
0.59 to 2.21
Therapeutic Sham ultrasound Pain (VAS) 6wk after treatment MD, 0.51;
ultrasound plus plus splint 95% CI, 2.01 to 0.99
splint (ITT analysis)
6wk after treatment MD, 0.26;
95% CI, 1.88 to 1.36 (per
protocol analysis)
Symptom severity score 6wk after treatment MD, .11;
95% CI, .52 to .30
(ITT analysis)
6wk after treatment MD, .13;
95% CI, .59 to .33 (per
protocol analysis)
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Functional status score 6wk after treatment MD, .21;

B.M. Huisstede et al
95% CI, .67 to .25
(ITT analysis)
6wk after treatment MD, .21;
95% CI, .73 to .31 (per
protocol analysis)
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Appendix 3 (continued )
No. of
Study Patients Treatment Placebo Control/Comparison Outcome Measures Effect Size
Therapeutic Therapeutic Pain (VAS) 6wk after treatment MD, 1.79; 95%
ultrasound plus ultrasound plus CI, 0.55 to 3.03 (ITT analysis)
splint splint plus In favor of ultrasound plus splint
ketoprofen plus ketoprofen phonophoresis.
phonophoresis 6wk after treatment MD, 2.22; 95%
CI, 0.99 to 3.45; (per protocol
analysis)
In favor of ultrasound plus splint
plus ketoprofen phonophoresis.
Symptom severity score 6wk after treatment MD, .34; 95%
CI, .04 to .72 (ITT analysis)
6wk after treatment MD, .32;
95% CI, .10 to .74 (per
protocol analysis)
Functional status score 6wk after treatment MD, .19; 95%
CI, .24 to .62 (ITT analysis)
6wk after treatment MD, .20; 95%
CI, .28 to .68 (per protocol
analysis)
NOTE. X denotes the use of a placebo group.
Abbreviations: BCTQ, Boston Carpal Tunnel Questionnaire; CI, confidence interval; DASH, Disabilities of the Arm, Shoulder and Hand; ITT, intention to treat; MD, mean difference; MVAS, mechanical visual
analogue scale; NRS, numeric rating scale; NSAID, nonsteroidal anti-inflammatory drug; RR, relative risk; VAS, visual analog scale; WHOQOLF, World Health Organization Quality of Life.

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22
Outcome Measures
(Total Follow-up
Study Treatment Placebo Control/Comparison Time) Results: P Results: Outcome Measures
54
Gunay and Alp Group 1: carpal bone Group 2: neutral volar night Handgrip strength Between-group Group 1 median (min to max) change from
2015 mobilization (10min/d, splint (nZ20) (0wk, 3mo) comparison of baseline to 3mo, .13 (.25 to .56) vs group 2
3 times/wk, for 10d) þ change scores, change from baseline to 3mo, .05 (.38 to
neutral volar night splint PZ.17 .50).
(nZ20) Pinchgrip strength Between-group Group 1 median (min to max) change from
(0wk, 3mo) comparison of baseline to 3mo, .13 (.33 to 1.33) vs group 2
change scores, change from baseline to 3mo, 0 (.43 to
PZ.04 1.14).
BCTQ SSS (0wk, 3mo) Between-group Group 1 median (min to max) change from
comparison of baseline to 3mo, 12.5 (26 to 5) vs group 2
change scores, change from baseline to 3mo, 8.0 (23 to
PZ.39 5).
BCTQ FSS (0wk, 3mo) Between-group Group 1 median (min to max) change from
comparison of baseline to 3mo, 5.5 (18 to 2) vs group 2
change scores, change from baseline to 3mo, 0 (11 to 5).
PZ.01
Pain intensity at Between-group Group 1 median (min to max) change from
night (VAS) (0wk, comparison of baseline to 3mo, 5 (8 to 2) vs group 2
3mo) change scores, change from baseline to 3mo, 4 (8 to 2).
PZ.14
Pain intensity at day Between-group Group 1 median (min to max) change from
(VAS) (0wk, 3mo) comparison of baseline to 3mo, 2 (7 to 2) vs group 2
change scores, change from baseline to 3mo, 3 (7 to 4).
PZ.53
Oskouei et al61 Treatment group: Control group: routine Pain (VAS) (0, 4wk) Between-group Treatment group mean  SD from 5.561.9 at
2014 neuromobilization physiotherapy (neutral difference in baseline to 2.681.62 at 4wk, percentage
maneuver combined with position night splint for percentage improvement from 0 to 4wk is 45%; control
routine physiotherapy 4wk, TENS 20min/ improvement, group mean  SD from 4.432.5 at baseline
(neutral position night session, 3d/wk at a P>.05 to 3.313.05 at 4wk, percentage improvement
splint for 4wk, TENS frequency of 80Hz, pulse from 0 to 4wk is 23%.
20min/session, 3d/wk at duration 60ms, and BCTQ SSS (0, 4wk) Between-group Treatment group mean  SD from 2.55.70 at
a frequency of 80Hz, therapeutic ultrasound difference in baseline to 1.53.53 at 4wk, percentage
pulse duration 60ms, and 5min/session, 3d/wk at a percentage improvement from 0 to 4wk is 37% vs; control
therapeutic ultrasound frequency of 1MHz, improvement, group mean  SD from 2.28.9 at baseline to
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5min/session, 3d/wk at a intensity of 1W/cm2, P>.05 1.7.72 at 4wk, percentage improvement from

B.M. Huisstede et al
frequency of 1MHz, duty cycle of 20%) 0 to 4wk is 23%.
intensity of 1W/cm2, (nZ16 hands) BCTQ FSS (0, 4wk) Between-group Treatment group mean  SD from 2.64.60 at
duty cycle of 20%) difference in baseline to 1.76.43 at 4wk, percentage
(nZ16 hands) percentage improvement from 0 to 4wk is 31%; control
improvement, group mean  SD from 2.12.70 at baseline
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Outcome Measures
(Total Follow-up
Study Treatment Placebo Control/Comparison Time) Results: P Results: Outcome Measures
PZ.004 to 1.92.67 at 4wk, percentage improvement
from 0 to 4wk is 23%.
Hains et al49 Experimental group: Control group: ischemic SSS and FSS (0wk, No between-group Experimental group mean difference  SD
2010 ischemic compression for compression on latent or 3wk, 30d after comparison expressed as percentages from baseline to
trigger points and taut active trigger points treatment, 10wk reported. 3wk, 4221; baseline to 30d after treatment,
bands in: m. biceps located in the [crossover group Experimental group 4521; baseline to 6mo, 3623; Control
brachii, bicipital supraspinatus area, only], 6mo) at both follow-up group mean difference  SD expressed as
aponeurosis, m. pronator deltoid area, evaluations, percentages from baseline to 3wk, 2618;
teres, m. subscapularis. infraspinatus area P<.0001; control baseline to 10wk [after crossover], 4815. No
5e15s of pressure per group after 6mo values reported.
trigger point, per crossover,
location. 15 treatments, P<.001.
3 times/wk, for 5wk. 15 treatments, 3 times/wk, Perceived Between-group Experimental group mean  SD expressed as
(nZ37) for 5wk. After initial 15 improvement comparison at percentages from baseline to 3wk, 6726;
treatments, subjects were (0wk, 3wk, 30d 3wk, P<.021; no baseline to 30d after treatment, 6730;
offered to continue with after treatment, P values reported baseline to 6mo, 5635; control group mean
another 15 treatments; 10wk [crossover for other points in  SD expressed as percentages from baseline
this time they received group only], 6mo) time. to 3wk, 5025; baseline to 10wk [after
the experimental crossover], 7521. No 6mo values reported.
treatment (nZ18 for first
15 treatments, nZ13 for
second 15 treatments)
Pratelli et al62 Group A: fascial Group B: LLLT wave-length BCTQ SSS (0wk, 10d Between-group Group A mean  SD from 3.03.77 at baseline to
2015 manipulation 45min, 1 780e830Nm, power 1000e after last comparison at 10d 1.36.27 at 10d after treatment to 1.28.28
time/wk for 3wk 3000mW, 5 daily sessions treatment, 3mo and at 3mo, 3mo after treatment; group B mean  SD from
(nZ35 hands) each 10min (nZ35 after last P<.0001 3.05.35 at baseline to 2.67.47 at 10d after
hands) treatment) treatment to 3.00.31 at 3mo after treatment
BCTQ FSS (0wk, 10d Between-group Group A mean  SD from 3.10.98 at baseline to
after last comparison at 10d 1.41.30 at 10d after treatment to 1.32.32
treatment, 3mo and at 3mo, 3mo after treatment; group B mean  SD from
after last P<.0001 2.90.89 at baseline to 2.58.79 at 10d after
treatment) treatment to 2.63.94 at 3mo after treatment
Pain (VAS) (0wk, 10d Between-group Group A mean  SD from 6.002.60 at baseline
after last comparison at 10d to 0.8.96 at 10d after treatment to .71.93
treatment, 3mo and at 3mo, 3mo after treatment; group B mean  SD from
after last P<.0001 5.512.24 at baseline to 5.002.07 at 10d
treatment) after treatment to 5.032.02 at 3mo after
treatment
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Appendix 4 (continued )
Outcome Measures
(Total Follow-up
Study Treatment Placebo Control/Comparison Time) Results: P Results: Outcome Measures
Madenci et al63
Group I: neutral position Group II: neutral position Hand grip strength Between-group Group I mean  SD from 25.46.3 at baseline to
2012 night splint for 6mo night splint for 6mo þ right (kg) (0, 6wk) difference at 6wk, 30.35.2 at 6wk; group II mean  SD from
þMadenci massage tendon and nerve gliding PZ.042. 25.75.9 at baseline to 28.23.2 at 6wk.
technique daily for 3min exercises 3 times/d. Hand grip strength Between-group Group I mean  SD from 21.23.2 at baseline to
with weekly follow-up (nZ40) left (kg) (0, 6wk) difference at 6wk, 26.92.6 at 6wk; group II mean  SD from
visits þ tendon and PZ.041. 20.53.3 at baseline to 24.12.3 at 6wk.
nerve gliding exercises BCTQ SSS (0, 6wk) Between, group Group I mean  SD from 3.91.1 at baseline to
3 times/day. (nZ40) difference at 6wk, 1.8.40 at 6wk; group II mean  SD from
PZ.001. 3.71.0 at baseline to 2.5.50 at 6wk.
BCTQ FSS (0, 6wk) Between-group Group I mean  SD from 3.2.80 at baseline to
difference at 6wk, 2.0.40 at 6wk; group II mean  SD from
PZ.001. 3.2.60 at baseline to 2.6.60 at 6wk.
Patient Global Between-group Group I mean  SD from 8.51.1 at baseline to
Assessment difference at 6wk, 2.3.80 at 6wk; group II mean  SD from
(0, 6wk) PZ.001 8.21.2 at baseline to 4.1.70 at 6wk.
Physician Global Between-group Group I mean  SD from 5.9.80 at baseline to
Assessment difference at 6wk, 1.2.50 at 6wk; group II mean  SD from
(0, 6wk) PZ.001 5.1.90 at baseline to 2.7.80 at 6wk.
Armagan et al56 Continuous ultrasound Sham ultrasound Pulsed ultrasound therapy, Symptom severity PZ.442 at 3wk Continuous ultrasound group mean  SD from
2014 therapy frequency 1MHz, therapy 1 time/d, frequency 1MHz, score (0, 3wk) 26.608.11 at baseline to 23.068.13 at 3wk;
intensity 1W/cm2, 1 5 times/wk, 3 wk intensity 1W/cm2, pulsed pulsed ultrasound group from 29.757.71 at
time/d, 5 times/wk, 3wk (nZ15) mode duty cycle 1:4, 1 baseline to 22.068.73 at 3wk; sham
(nZ15) time/d, 5 times/wk, 3wk ultrasound group from 25.934.46 at baseline
(nZ16) to 19.664.60 at 3wk.
Functional status PZ.125 at 3wk Continuous ultrasound group mean  SD from
score (0, 3wk) 21.337.37 at baseline to 18.807.34 at 3wk;
pulsed ultrasound group from 24.005.58 at
baseline to 19.319.42 at 3wk; sham
ultrasound group from 19.000.85 at baseline
to 14.204.52 at 3wk.
Pain (VAS) (0, 3wk) PZ.083 at 3wk Continuous ultrasound group mean  SD from
5.402.32 at baseline to 4.402.32 at 3wk;
pulsed ultrasound group from 5.561.75 at
baseline to 2.681.92 at 3wk; sham
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B.M. Huisstede et al
ultrasound group from 5.201.26 at baseline
to 3.531.95 at 3wk.
Paoloni et al44 ESWT group: 4 sessions over Ultrasound group: received Pain (VAS) (0, 3, 7, Between-group No exact mean (difference)  SD values
2015 3wk of low-intensity 15 sessions of ultrasound, 15wk) comparison for reported. Two-way ANOVA revealed no
focused ESWT (2500 5 sessions/wk, for 3wk, factor treatment, significant effect for factor treatment
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Outcome Measures
(Total Follow-up
Study Treatment Placebo Control/Comparison Time) Results: P Results: Outcome Measures
2
pulses, .05mJ/mm ) 15min/session PZ.72, factor (between group), the effect for the factor time
(8 subjects, 12 wrists) (frequency 1MHz, timetreatment, (within group) was a significant interaction,
intensity 1.0W/cm2, PZ.82 and timetreatment was not significant
pulsed mode 1:4) Paresthesia (VAS) Between-group No exact mean (difference)  SD values
(8 subjects, 13 wrists) (0, 3, 7, 15wk) comparison for reported. Two-way ANOVA revealed no
factor treatment, significant effect for factor treatment
PZ.07, factor (between group), the effect for the factor time
timetreatment, (within group) was significant, interaction
PZ.79 timetreatment was not significant.
Cryoultrasound group Levine-Boston Post hoc between- No exact mean (difference)  SD values
received 15 sessions of Questionnaire for group comparison reported. Two-way ANOVA revealed a
ultrasound, 5 sessions/ CTS severity of for factor significant effect for factor treatment
wk, for 3wk, 15min/ hand symptoms treatment ESWT (between group), the effect for the factor time
session (temperature of (0, 3, 7, 15wk) group compared (within group) was significant, and interaction
0 C on the skin, with ultrasound or timetreatment was not significant. Post hoc
frequency 1MHz, cryoultrasound comparison showed that ESWT group scores
intensity 1.0W/cm2, group, P<.05 were better than those of group ultrasound or
pulsed mode 1:4) group cryoultrasound.
(9 subjects, 17 wrists) Levine-Boston Between-group No exact mean (difference)  SD values
Questionnaire for comparison for reported. Two-way ANOVA revealed no
CTS functional factor Treatment, significant effect for factor treatment
status P>.05, factor (between group), the effect for the factor time
(0, 3, 7, 15wk) timetreatment, (within group) was significant, and interaction
PZ.85 timetreatment was not significant.
Wu et al45 2016 Intervention group; radial Placebo group Pain (VAS) P<.001 at 4wk, Intervention group mean change  SD from
extracorporeal shockwave placebo radial (baseline, 4wk, P<.001 at 7wk, baseline to 4wk 3.22.90, baseline to 7wk
therapy 2000 shots, at extracorporeal 7wk, 11wk, 15wk) PZ.003 at 11wk, 3.891.23, baseline to 11wk 3.591.49,
4-bar pressure, and a shockwave PZ.006 at 15wk baseline to 15wk 3.671.47; control group
5-Hz frequency 1 time/wk therapy plus mean change  SD from baseline to 4wk
for 3wk, plus neutral neutral night wrist 1.441.05, baseline to 7wk 1.791.19,
night wrist splint. splint. (nZ17) baseline to 11wk 2.101.44, baseline to
(nZ17) 15wk 2.321.47.
BCTQ SSS (baseline, PZ.017 at 4wk, Intervention group mean change  SD from
4wk, 7wk, 11wk, PZ.005 at 7wk, baseline to 4wk 12.458.97, baseline to
15wk) PZ.008 at 11wk, 7wk 13.757.83, baseline to 11wk
PZ.171 at 15wk 15.158.58, baseline to 15wk
14.208.67; control group mean
change  SD from baseline to 4wk
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Appendix 4 (continued )
Outcome Measures
(Total Follow-up
Study Treatment Placebo Control/Comparison Time) Results: P Results: Outcome Measures
6.206.65, baseline to 7wk 6.507.42,
baseline to 11wk 7.957.76, baseline to
15wk 10.159.67.
BCTQ FSS (baseline, PZ.001 at 4wk, Intervention group mean change  SD from
4wk, 7wk, 11wk, PZ.002 at 7wk, baseline to 4wk 5.95.62, baseline to 7wk
15wk) PZ.002 at 11wk, 6.803.83, baseline to 11wk 7.003.77,
PZ.007 at 15wk baseline to 15wk 7.103.60; control group
mean change  SD from baseline to 4wk
2.352.96, baseline to 7wk 2.953.66,
baseline to 11wk 2.704.28, baseline to
15wk 3.154.98.
Finger pinch PZ.852 at 4wk, Intervention group mean change  SD form
strength (kg) PZ.811 at 7wk, baseline to 4wk .90.68, baseline to 7wk
(baseline, 4wk, PZ.505 at 11wk, 1.18.78, baseline to 11wk 1.39.71,
7wk, 11wk, 15wk) PZ.912 at 15wk baseline to 15wk 1.771.01; control group
mean change  SD from baseline to 4wk
.95.89, baseline to 7wk 1.25.97, baseline
to 11wk 1.581.02, baseline to 15wk
1.741.08.
Seok and Kim46 ESWT group: location Injection group: local Pain (VAS) No significant ESWT group mean  SD from 7.061.89 at
2013 determined by anesthetic 1mL lidocaine, (0wk, 1mo, 3mo) difference baseline to 4.56.81 at 1mo to 4.181.05 at
ultrasonography, each and a single between groups, 3mo; injection group mean  SD from
patient received 1 ultrasonographic-guided no P value 6.871.26 at baseline to 4.131.50 at 1mo to
session of ESWT, 1000 injection with 1mL of reported. 3.311.82 at 3mo.
shocks, frequency 360 40mg triam cinolone Levise self- No significant ESWT group mean  SD from 31.2711.41 at
shocks/min, energy level acetonide. (nZ16) assessment difference baseline to 20.136.24 at 1mo to 19.734.48
maximum toleration questionnaire between groups, at 3mo; injection group mean  SD from
(.09e.29mJ/mm2). symptom severity no P value 28.5010.01 at baseline to 18.253.71 at
(nZ15) score reported. 3mo. No mean  SD values reported for the
(0wk, 1mo, 3mo) measurement at 1mo.
Levise self- No significant No mean  SD values reported for either
assessment difference group/point in time.
questionnaire between groups,
functional status no P value
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B.M. Huisstede et al
score (0wk, 1mo, reported.
3mo)
Notarnicola ESWT group; 3 sessions Nutraceutical group: Pain (VAS) (0wk, Between-group ESWT group mean  SD from 6.22.4 at baseline
et at57 2015 (1 per wk) of shockwave received a diet 1mo, 2mo, 4mo, differences: at to 4.12.7 at 1mo to 3.63.2 at 2mo to
therapy; average of 1600 supplementary mainly 6mo) 1mo PZ.23, at 3.93.1 at 4mo to 2.52.5 at 6mo;
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Physical therapy and electrophysical modalities for CTS

Appendix 4 (continued )
Outcome Measures
(Total Follow-up
Study Treatment Placebo Control/Comparison Time) Results: P Results: Outcome Measures
shocks (800 medial, 800 composed of alpha lipoic 2mo PZ.46, at nutraceutical group mean  SD from 7.41.9
lateral) at an energy flux acid, conjugated linoleic 4mo PZ.44, at at baseline to 4.82.8 at 1mo to 3.52.4 at
density of .03mJ/mm2, acid, and echinacea, 1 6mo PZ.36. 2mo to 3.12.1 at 4mo to 2.21.5 at 6mo.
frequency 4Hz. (nZ34) capsule twice a day for BCTQ SSS (0wk, 1mo, Between-group ESWT group mean  SD from 32.58.7 at
40d, after 1 capsule a day 2mo, 4mo, 6mo) differences: at baseline to 24.68.1 at 1mo to 21.99.2 at
for 80da. (nZ26) 1mo PZ.27, at 2mo to 20.310.1 at 4mo to 18.67.8 at
2mo PZ.47, at 6mo; nutraceutical group mean  SD from
4mo PZ.44, at 33.16.6 at baseline to 26.59.6 at 1mo to
6mo PZ.33. 21.76.6 at 2mo to 19.86.3 at 4mo to
17.64.6 at 6mo.
BCTQ FSS (0wk, 1mo, Between-group ESWT group mean  SD from 23.16.3 at
2mo, 4mo, 6mo) differences: at baseline to 18.47.0 at 1mo to 18.38.6 at
1mo PZ.24, at 2mo to 16.58.1 at 4mo to 14.86.4 at 6mo;
2mo PZ.45, at nutraceutical group mean  SD from 24.15.9
4mo PZ.42, at at baseline to 20.26.9 at 1mo to 18.66.8 at
6mo PZ.43. 2mo to 17.06.2 at 4mo to 15.25.9 at 6mo.
Perception of Between-group ESWT group mean  SD at 6mo was 1.5.70 vs
improvement difference PZ.29. nutraceutical group 1.3.50
(Roles and
Maudsley score)
(6mo)
Weintraub and Dynamic magnetic field Sham therapy (nZ19) Pain (VAS) (2mo) Not significant Treatment group: from 6.822.08 (mean  SD)
Cole58 2008 stimulation to the wrist No P value given at baseline to 4.152.13 at 2mo; sham
4h/d for 2mo (nZ17) PZ.04 therapy: from 5.171.54 at baseline to
3.782.27 at 2mo
NPS Reduction: treatment group* 42% vs controls
NPS total composite 24%
(2mo)
Patients Clinical PZ.12 No exact data given
Global Impression
of Change (2mo)
Colbert et al8 Static magnetic field 0mT group. (nZ20) Static magnetic field BCTQ SSS Between-group 15mT group mean change  SD .70.60 from
2010 therapy w15e20mT therapy w45e50mT (0, 6, 18wk) comparisons of baseline to 6wk, .50.80 from baseline to
(15mT group), magnet (45mT group), magnet change scores 18wk; 45mT group mean change  SD .80.60
worn during the night for worn during the night for from baseline to from baseline to 6wk, .70.60 from baseline
7d/wk for 6wk. (nZ20) 7d/wk for 6wk. (nZ20) 6wk PZ.689 to 18wk; 0mT group mean change  SD
baseline to 18wk .90.90 from baseline to 6wk, .60.70 from
PZ.463. baseline to 18wk.

27
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Appendix 4 (continued )
Study Treatment
Arikan et al43 Pulsed magnetic field
2011 therapy by using 2-
channel magnet therapy
30min/session,
(5 times/wk for 3wk).
(nZ19)
Michlovitz60 Heat wrap with heat to
2004 104 F (40 C) for 8h daily
(this temperature
maintained continuously
because of exposure to
air) for 3d. (nZ10)
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28
Outcome Measures
(Total Follow-up
Placebo Control/Comparison Time) Results: P Results: Outcome Measures
BCTQ FSS (0, 6, Between-group 15mT group mean change  SD .50.70 from
18wk) comparisons of baseline to 6wk, .20.80 from baseline to
change scores 18wk; 45mT group mean change  SD .60.60
from baseline to from baseline to 6wk, .40.60 from baseline
6wk PZ.686, to 18wk; 0mT group mean change  SD
baseline to 18wk .70.80 from baseline to 6wk, .50.80 from
PZ.722. baseline to 18wk.
(nZ19) Pain (VAS) (0-, 3-, P>.05 Active group mean difference before to after
7-wk follow-up) treatment mean  SD .962.62; active group
difference before to 1mo follow-up .523.08;
sham group mean difference before to after
treatment mean  SD 1.262.65; sham group
mean difference group before treatment to
1mo follow-up 1.252.90.
SSS (0-, 3-, 7-wk P>.05 Active group mean difference before to after
follow-up) treatment mean  SD .81.73; active group
mean difference before to 1mo follow-up
.601.19; sham group mean difference before
to after treatment mean  SD .63.55; sham
group mean difference group before treatment
to 1-mo follow-up .46.69.
Frequency of waking P>.05 Active group mean difference before to after
up at night by treatment mean  SD .591.08; active group
symptoms mean difference before to 1-mo follow-up
(awakening score) .361.31; sham group mean difference before
(0-, 3-, 7-wk to after treatment mean  SD .631.12; sham
follow-up) group mean difference group before treatment
to 1-mo follow-up .421.13.
Oral placebo for 3d 4 times Pain relief (5d) PZ.001 Heat wrap*: 2.180.34 (mean  SD) vs oral
daily, 2 tablets. (nZ12) placebo: 0.950.25 at day 1e3/hour 0e8
P
.05 Heat wrap* vs oral placebo at 20 of 26 time
points
Joint stiffness PZ.004 Heat wrap*: 21.85.5 (mean  SD) vs oral
reduction (5d) placebo: 4.93.1 at day 1e3/hour 0e8
B.M. Huisstede et al
P
.05 Heat wrap* vs oral placebo at 19 of 26 time
points
Grip strength (5d) PZ.012 Heat wrap*: 6.11.6kg (mean  SD) vs oral
placebo: 0.81.4kg at 5-d follow-up
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Physical therapy and electrophysical modalities for CTS

Appendix 4 (continued )
Outcome Measures
(Total Follow-up
Study Treatment Placebo Control/Comparison Time) Results: P Results: Outcome Measures
Patient-rated wrist PZ.013 Heat wrap*: 27.35.9 (mean  SD) vs oral
evaluation placebo: 7.95.39 at 5-d follow-up
Levine CTS
Questionnaire
SSS P
.001 Heat wrap*: 0.970.16 (mean  SD) vs oral
placebo: 0.140.14 at 5-d follow-up
FSS PZ.006 Heat wrap 0.650.16 (mean  SD) vs oral
placebo: 0.000.16 at 3-d follow-up
PZ.07 Heat wrap: 0.570.22 (mean  SD) vs oral
placebo: 0.120.20 at day 5
Frasca et al51 Hyperthermia treatment (nZ11) Pain (VAS) (0, after Pretreatment Hyperthermia group: median score, 8
2011 20min/session, 8 first 2 simulated eposttreatment (interquartile range, 6e9) and range 3e10 at
sessions, 2 times/wk of sessions at 1, between-group baseline to 6 (interquartile range, 5.25e8)
which first 2 were 4wk) comparison range 0e8 at 4wk vs Placebo group: median
placebo sessions (start- PZ.004 score, 6 (interquartile range, 6e7) and range
delayed Design). (nZ11) 2e10 at baseline to 6 (interquartile range,
6e7.75) and range 4e8 at 4wk.
Levine Boston Pretreatment Hyperthermia group: median score, 2.27
Questionnaire part eposttreatment (interquartile range, 1.64e3.50) and range
1 (0, after first 2 between-group 1e4.55 at baseline to 1.73 (interquartile
simulated sessions comparison range, 1.27e2.50) range 1e3.73 at 4wk vs
at 1, 4wk) PZ.009 placebo group: median score, 2.36
(interquartile range, 1.68e2.90) and range
1.36e3.54 at baseline to 2.23 (interquartile
range, 1.68e2.71) and range 1.30e3.40 at
4wk.
Levine Boston Pretreatment Hyperthermia group: median score, 2
Questionnaire part eposttreatment (interquartile range, 1.25e2.74) and range
2 (0, after first between-group 1e4.50 at baseline to 1.50 (interquartile
2 simulated comparison range, 1.13e2.00) range 1.00e4.00 at 4wk vs
sessions at 1, P>.05, no exact placebo group: median score, 2.00
4wk) P value reported (interquartile range, 1.50e2.56) and range
1.13e4.13 at baseline to 1.98 (interquartile
range, 1.49e2.63) and range 1.13e4.07 at
4wk.
Amirjani et al47 Iontophoresis with 0.4% Iontophoresis with distilled Levine CTS PZ.73 Treatment group: mean, 38 (25%e75% CI,
2009 dexamethasone sodium water (control group). Questionnaire 31e40) vs control group: mean, 36
phosphate with distilled (nZ8) (6mo) (25%e75% CI, 33e54) at baseline
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29
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Appendix 4 (continued )
Outcome Measures
(Total Follow-up
Study Treatment Placebo Control/Comparison Time) Results: P Results: Outcome Measures
water (treatment group). PZ.97 Treatment group: mean, 33 (25%-75% CI,
(nZ9) 24e44) vs control group: mean, 32
(25%e75% CI, 26e37) at 3-mo follow-up
PZ.25 Treatment group: mean, 26 (25%e75% CI,
24e31) vs control group: mean, 34
(25%e75% CI, 22e41) at 6-mo follow-up
Bakhtiary et al48 Group A: iontophoresis of Group B: phonophoresis 4g Pain (VAS) PZ.001 Group A mean change  SD from baseline to end
2013 0.4% Dex-P, using direct aquasonic gel with 0.4% (baseline, 2wk at of intervention 2.11.9, group B from
current 2mA/min, total Dex-P, 20% pulsed end of therapy, baseline to end of intervention 4.2.90;
dose 40mA/min for ultrasound waves, 4wk follow-up) mean difference, 2.1; 95% CI, 1.3e2.9
20min, 5 times/wk for intensity 1.0W/cm2, PZ.008 Group A mean change  SD from baseline to
2wk. (nZ26 hands) frequency 1MHz, duration 4-wk follow-up 2.31.9, group B from
5min/session, baseline to follow-up 4.11.2; mean
5 times/wk for 2wk. difference, 1.8; 95% CI, 0.9e2.7
(nZ26 hands) Pinch strength PZ.0002 Group A mean change  SD from baseline to end
(pinch gauge) of intervention 12.918.9, group B from
(baseline, 2wk at baseline to end of intervention 44.56.2;
end of therapy, mean difference, 31.6; 95% CI, 15.9e47.3
4-wk follow-up) PZ.0001 Group A mean change  SD from baseline to
4-wk follow- up 5.318.2, group B from
baseline to follow-up 34.715.1; mean
difference, 29.4; 95% CI, 11.3e47.5
Hand grip strength PZ.006 Group A mean change  SD from baseline to end
(handheld of intervention t28.823.2, group B from
dynamometer) baseline to end of intervention 55.826.1;
(baseline, 2wk at mean difference, 27.1; 95% CI, 13.5e40.5
end of therapy, PZ.032 Group A mean change  SD from baseline to
4-wk follow-up) 4-wk follow-up 5.318.2, group B from
baseline to follow-up 34.715.1; mean
difference, 29.4; 95% CI, 12.6e41.7
Gurcay et al59 Group I: phonophoresis Group II: iontophoresis, BCTQ SSS (0wk, 3mo) Between-group No exact mean  SD reported, only bar charts.
2012 0.1% betamethasone, 0.1% betamethasone, difference,
frequency 1MHz, from the positive PZ.015; Post hoc
intensity 1W/Cm2, electrode, dosage 2mA, comparison only
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continuous mode, 10min/
d, 3d/wk, for 3wk þ
wrist splint, night only
for 3wk. (nZ18)
B.M. Huisstede et al
10min/d, 3d/wk, for 3wk significant
þ wrist splint, night only between group I
for 3wk. (nZ18) and III, in favor of
group I, PZ.012
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Appendix 4 (continued )
Outcome Measures
(Total Follow-up
Study Treatment Placebo Control/Comparison Time) Results: P Results: Outcome Measures
Grip strength Between-group No exact mean  SD reported, only bar charts.
(0wk, 3mo) difference,
PZ.280
Group III: wrist splint, Hand function Between-group No exact mean  SD reported, only bar charts.
night only for 3wk. (Nine-Hole Peg difference,
(nZ18) Test) (0wk, 3mo) PZ.811
Raeissadat et al52 Bioptron group: polarized Control group: neutral wrist Pain (VAS) (0, 8wk) Between-group Bioptron group mean  SD from 6.21.38 at
2014 poly chromatic splint for 8wk. (nZ23) difference at 8wk, baseline to 3.782.19 at 8wk; control group
noncoherent light PZ.685 mean  SD from 5.91.34 at baseline to
(bioptron) wavelength 3.622.01 at 8wk.
480e3400Nm, power of Severity of disease No statistical test Bioptron group severity of disease before
Halogen 90W, degree of (0, 8wk) reported treatment 65.2% mild, 34.8% moderate; at
polarization 95%, 8wk 26.1% normative, 56.5% mild, 17.4%
specific power density moderate; control group severity of disease
40mW/cm2, energy before treatment 61.9% mild, 38.1%
density 2.4J/cm2, 8min/ moderate; at 8wk 28.5%, 52.5% mild, 19%
session 3sessions/wk, for moderate.
4wk, plus a neutral wrist
splint for 8wk. (nZ27)
Chen et al53 2015 Ultrasound-guided PRF PRF, Wrist splint at night and Pain (VAS) Between-group PRF group mean difference  SD from baseline to
1 session, 120s at 2Hz 8h/d for 12wk. (nZ18) (1, 4, 8, 12wk comparisons of 1wk 2.91.1 (95% CI, 2.4e3.4), baseline to
frequency, pulse width after treatment) change scores 4wk 3.21.1 (95% CI, 2.6e3.7), baseline to
20ms at 42 C þ wrist from baseline to 8wk 3.61.6 (95% CI, 2.8e4.4), baseline to
splint at night and 8h/d 1wk, PZ.002; 12wk 4.22.1 (95% CI, 3.2e5.2); control
for 12wk. (nZ18) baseline to 4wk, group mean difference  SD from baseline to
PZ.013; baseline 1wk 1.11.2 (95% CI, 0.5e1.7), baseline to
to 8wk, P<.001; 4wk 1.61.4 (95% CI, 0.9e2.2), baseline to
baseline to 12wk, 8wk 1.81.5 (95% CI, 1.0e2.5), baseline to
P<.001 12wk 2.01.8 (95% CI, 1.1e2.9).
Median onset time P<.001 for median Kaplan-Meier survival analysis PRF group median
(no. of days) of onset time; hazard onset time 2d vs control group 14d; hazard
significant pain ratio, P<.001 ratio 7.37 (95% CI, 3.04e17.87)
(VAS) relief
BCTQ SSS Between-group PRF group mean difference  SD (95% CI) from
(1, 4, 8, 12wk comparisons of baseline to 1wk 11.74.7 (95% CI,
after treatment) change scores 9.4e14.1), baseline to 4wk 13.95.1
from baseline to (95% CI, 11.3e16.4), baseline to 8wk
1wk, PZ.077; 16.36.3 (95% CI, 13.2e19.4), baseline to

31
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Appendix 4 (continued )
Outcome Measures
(Total Follow-up
Study Treatment Placebo Control/Comparison Time) Results: P Results: Outcome Measures
baseline to 4wk, 12wk 19.76.7 (95% CI, 16.4e23.0);
PZ.037; baseline control group mean difference  SD from
to 8wk, PZ.004; baseline to 1wk 7.06.6 (95% CI,
baseline to 12wk, 3.7e10.3), baseline to 4wk 9.47.7
P<.001 (95% CI, 5.6e13.3), baseline to 8wk
10.28.7 (95% CI, 5.9e14.5), baseline to
12wk 10.99.2 (95% CI, 6.3e15.5).
BCTQ FSS Between-group PRF group mean difference  SD from baseline to
(1, 4, 8, 12wk comparisons of 1wk 11.24.6 (95% CI, 8.9e13.4), baseline
after treatment) change scores to 4wk 12.14.3 (95% CI, 10e14.3),
from baseline to baseline to 8wk 12.65 (95% CI,
1wk, PZ.032; 10.1e15.1), baseline to 12wk 14.24.1
baseline to 4wk, (95% CI, 12.2e16.3); control group mean
PZ.025; baseline difference  SD from baseline to 1wk
to 8wk, PZ.016; 6.96.3 (95% CI, 3.8e10), baseline to 4wk
baseline to 12wk, 8.66.8 (95% CI, 5.2e11.9), baseline to
PZ.001 8wk 8.87.0
(95% CI, 5.3e12.2), baseline to 12wk
9.37.4 (95% CI, 5.6e13.0).
Finger pinch (kg) Between-group PRF group mean difference  SD from baseline to
(1, 4, 8, 12wk comparisons of 1wk 1.0.6 (95% CI, 1.3 to 0.7), baseline
after treatment) change scores to 4wk 1.6.8 (95% CI, 2.0 to 1.2),
from baseline to baseline to 8wk 1.9.9 (95% CI, 2.4 to
1wk, PZ.282; 1.5), baseline to 12wk 2.31.0
baseline to 4wk, (95% CI, 2.8 to 1.8); control group mean
PZ.169; baseline difference  SD from baseline to 1wk 0.70.6
to 8wk, PZ.205; (95% CI, 1.0 to 0.4), baseline to 4wk
baseline to 12wk, 1.11.2 (95% CI, 1.7 to 0.5), baseline to
PZ.138 8wk 1.61 (95% CI, 2.2 to 1.1), baseline
to 12wk 1.81.2 (95% CI, 2.4 to 1.2).
Boyacı et al50 Group 1: continuous Group 3: (nZ10) Group 2: pulsed shortwave Pain (VAS) (0, 3wk) PZ.315 for VAS Group 1 mean  SD from baseline 7.632.13 to
2014 shortwave diathermy diathermy pulse duration mean change 5.522.69 at 3wk, mean change  SD
intensity position 4, 15 400ms, pulse frequency between groups 1.891.97; group 2 mean  SD from
sessions, 20min/d, 5d/ 82Hz, intensity position baseline 7.851.53 to 5.652.20 at 3wk,
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B.M. Huisstede et al
wk, 3wk. (nZ10) 6, 15 sessions, 20min/d, mean change  SD 2.201.88; group 3
5d/wk, 3wk. (nZ10) mean  SD from baseline 7.561.50 to
6.31.98 at 3wk, mean change  SD
1.252.46.
BCTQ SSS (0, 3wk) PZ.031 for BCTQ Group 1 mean  SD from baseline 37.109.59 to
SSS mean change 29.318.93 at 3wk, mean change  SD
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Physical therapy and electrophysical modalities for CTS

Appendix 4 (continued )
Outcome Measures
(Total Follow-up
Study Treatment Placebo Control/Comparison Time) Results: P Results: Outcome Measures
between groups, 7.785.23; group 2 mean  SD from
in favor of baseline 32.309.36 to 28.658.38 at 3wk,
continuous group. mean change  SD 3.654.54; group 3
mean  SD from baseline 32.127.22 to
29.568.67 at 3wk, mean change  SD
2.56 6.52.
BCTQ FSS (0, 3wk) PZ.132 for BCTQ Group 1 mean  SD from baseline 23.846.15 to
FSS mean change 20.06.19 at 3wk, mean change  SD
between groups 3.844.33; group 2 mean  SD from
baseline 20.106.26 to 17.905.98 at 3wk,
mean change  SD 2.203.38 vs; group 3
mean  SD from baseline 18.876.50 to
17.686.61 at 3wk, mean change  SD
1.182.07.
Koca et al55 2014 Group III interferential Group I night splint for Pain (VAS) (0, 6wk) Group I vs group III, Group I mean  SD from 8.31.61 at baseline to
current therapy, base 3wk, in neutral position. P<.01; group II vs 6.371.18 at 6wk; group II mean  SD from
frequency 4000Hz, (nZ25) group III, P<.01; 8.06.55 at baseline to 6.681.42 at 6wk;
modulation frequency all groups group III mean  SD from 8.250.4 at
range 20Hz, delta F 10Hz compared, baseline to 4.801.18 at 6wk.
and slope 1/1 in P<.001.
quadripolar mode, 15 BCTQ SSS (0, 6wk) Group I vs group III, Group I mean  SD from 4.211.18 at baseline
sessions, 20min/session, no P value to 3.121.11 at 6wk; group II mean  SD
5 times/wk, for 3wk. reported; group II from 4.061.02 at baseline to 3.371.21 at
(nZ25) vs group III, 6wk; group III mean  SD from 3.901.06 at
P<.05; all groups baseline to 2.701.03 at 6wk.
compared, PZ.007.
Group II TENS pulse rate BCTQ FSS (0, 6wk) Group I vs group III, Group I mean  SD from 3.121.28 at baseline
100Hz, stimulation no P value to 2.371.38 at 6wk; group II mean  SD
period 80ms, 15sessions, reported; group II from 2.931.26 at baseline to 2.50.78 at
20min/session, vs group III, 6wk; group III mean  SD from 2.801.24 at
5 times/wk, for 3wk. P<.05; all groups baseline to 1.901.21 at 6wk.
(nZ25) compared,
PZ.031.
Abbreviations: ANOVA, analysis of variance; BCTQ, Boston Carpal Tunnel Questionnaire; CI, confidence interval; Dex-P, dexamethasone sodium phosphate; m, musculus; max, maximum; min, minimum; NPS,
Neuropathy Pain Scale; PRF, pulsed radiofrequency; VAS, visual analog scale.
* In favor of which therapy group they differences within the study were found.

33
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