Effectiveness of Hand Therapy Interventions
in Primary Management of Carpal
Tunnel Syndrome:
A Systematic Review
Monique Muller, BSc, MScPT, PhD
Deborah Tsui, BSc, BA, MScPT
Ronda Schnurr, BA, MScPT
Lori Biddulph-Deisroth, BSc, MScPT
Julie Hard, BSc, MScPT
School of Rehabilitation Science
McMaster University
Hamilton, Ontario, Ontario
Joy C. MacDermid, BScPT, PhD
School of Rehabilitation Science
McMaster University
Hamilton, Ontario, Canada
Clinical Research Lab
Hand and Upper Limb Centre
St. Joseph’s Health Centre
London, Ontario, Canada
Career Scientist of the Ontario Ministry of Health
Health Research Personnel Development Program
Carpal tunnel syndrome (CTS) is a neurologic
disorder involving compression of the median nerve
in the carpal tunnel of the wrist.1–3 The pathophys-
iology of CTS is thought to involve gradual ischemia
and mechanical deformation of the median nerve
produced by elevated pressure within the carpal
tunnel.1 This leads to impaired nerve conduction and
signs of nerve dysfunction.1 Symptoms of CTS may
include sensory impairments such as tingling,
numbness, and pain of the hand, and motor impair-
ments such as weakness of the thenar muscles, and
loss of hand dexterity and function.1,3–5 Instead of
a steadily progressive disorder, CTS is characterized
by periods of remission and exacerbation.6,7 Hence, it
may have an unpredictable course and is potentially
a difficult condition to treat.
CTS occurs most commonly in individuals whose
occupations involve forceful repetitive hand move-
Research funding was provided by the Ontario Workplace Safety
and Insurance Board (WSIB).
Correspondence and reprint requests to Joy C. MacDermid,
BScPT, PhD, School of Rehabilitation Science, IAHS, 1400 Main
Street West, 4th Floor, Hamilton, Ontario, Canada L8S 1C7;
e-mail: <macderj@mcmaster.ca>.
doi:10.1197/j.jht.2004.02.009
210 JOURNAL OF HAND THERAPY
ABSTRACT: The purpose of this study was to determine the
effectiveness of hand therapy interventions for carpal tunnel
syndrome (CTS) based on the best available evidence. A
qualitative systematic review was conducted. A literature search
using 40 key terms was conducted from the earliest available date
to January 2003 using seven databases. Articles were randomly
assigned to two of five reviewers and evaluated according to
predetermined criteria for inclusion at each of the title, abstract,
and article levels. Included studies were independently scored by
two reviewers using a structured effectiveness quality evaluation
scale and also graded according to Sackett’s Levels of Evidence.
There were 2027 articles identified from the literature search, of
which 345 met the inclusion criteria. Twenty-four studies were
used to formulate 30 recommendations. Current evidence dem-
onstrates a significant benefit (grade B recommendations) from
splinting, ultrasound, nerve gliding exercises, carpal bone
mobilization, magnetic therapy, and yoga for people with CTS.
J HAND THER. 2004;17:210–228.
ments that either decrease the area within the carpal
tunnel or increase the volume of its contents.2,8,9
Although repetitive activity is an identified pre-
cipitating factor for the development of CTS, the
exact aetiology remains unclear.10 Other factors
believed to be related to CTS onset include ergo-
nomic stressors, systemic/endocrine disorders (ie,
diabetes mellitus, renal failure, thyroid disease,
rheumatoid arthritis), obesity, acute trauma, preg-
nancy, and psychosocial factors.2,11,12
Estimations of the prevalence of CTS in the general
population range from 1% to 3%13,14; however, it is
more prevalent within certain occupational popula-
tions such as meatpackers, cashiers, and keyboard-
users.15–17 Health care costs for CTS are estimated to
be from $5000 (US) per case10,16 for conservative
treatment to $60,000 (US) for surgical interventions.18
In the United States, carpal tunnel release is one of
the most common hand and wrist surgeries per-
formed, with approximately 400,000 conducted per
year.19 In the workplace, CTS results in lost days of
productivity and wages, high health care costs, and
constitutes a significant proportion of workers’
compensation claims.2,16,20
Beyond cost-effectiveness, there are several rea-
sons for choosing conservative interventions over
surgical treatment. First, in some localities, there may Research articles were excluded from review based
be a long wait for surgical intervention by transverse on the following criteria:
carpal ligament release.2 Second, there are risks of

The study subjects/patients’ mean age was less
perioperative injuries and postoperative complica-
than 18 years
tions such as nerve injury, infection, tendon injury,

The study subjects/patients had previous surgery
and reflex sympathetic dystrophy.2 Third, conserva-
for treatment of CTS
tive treatment may be effective in managing symp-

The study was not written in English
toms, and the scientific literature provides evidence

The study subjects/patients had traumatic CTS
in support of some conservative therapies.21,22

The study investigated prevention instead of
Hand therapists may use a variety of conservative
treatment of CTS
interventions in their management of persons with

The article was not primary a research study or
CTS. Two recent systematic reviews examined the
was deemed level 5 evidence (as defined by
effectiveness of such conservative therapies; how-
Sackett’s Levels of Evidence)23
ever, each included only randomized, controlled

The article’s source publication/journal was not
trials (level 1 evidence). Consequently, some thera-
peer-reviewed
peutic interventions were not reviewed despite the

The study’s intervention(s) was/were beyond the
presence of other levels of evidence in the literature
scope of physiotherapy/hand therapy/occupa-
that might support or refute their use.
tional therapy
The objective of this systematic review is twofold;

The study did not evaluate effects of the therapy
first, to review the literature in answer of the
intervention(s)
question: What is the effectiveness of hand therapy
interventions in the management of carpal tunnel
syndrome without prior surgical involvement? Sec- Inclusion/Exclusion and Critical Appraisal
ond, to identify strengths and limitations of current
research in hand therapy management of CTS. Five researchers (LBD, JH, MM, RS, and DT) were
involved in the process of inclusion/exclusion and
critical appraisal. Each study was evaluated for
inclusion in the review at three separate stages: title,
METHODS abstract, and article level. Articles retrieved from
each database were assessed at the title level by two
Literature Search different reviewers. Using a conservative approach,
any studies that reviewers disagreed on at the title
A literature search was conducted in January 2003
level were forwarded for reevaluation at the next
for clinical studies of therapy interventions for CTS.
stage. Studies remaining after title elimination were
Seven databases were searched from the earliest
randomized to two different reviewers by drawing
available date using 40 search terms (Appendix 1).
numbers out of a box. Each abstract was assessed for
These databases were MEDLINE (January 1966 to
inclusion independently by each reviewer. All in-
January 2003), CINAHL (January 1982 to January
cluded abstracts were then rerandomized to two new
2003), EMBASE (January 1980 to January 2003), the
reviewers by again drawing numbers out of a box.
Cochrane Controlled Trials Register (January 1964 to
Full articles were independently assessed by each
January 2003), PEDro (January 1929 to January 2003),
reviewer using the Structured Effectiveness Quality
Wilson Business Index (July 1982 to January 2003),
Evaluation Scale (SEQES) (Appendix 2). The SEQES
and ERIC (July 1989 to January 2003). The search was
is a recently developed critical appraisal tool and its
not restricted to randomized, controlled trials in an
reliability and validity are presently being evaluated.
effort to formulate recommendations based on the
The same reviewers also determined the study’s level
best available level of evidence. Inclusion and
of evidence based on Sackett’s Levels of Evidence
exclusion criteria were defined for the title, abstract,
(Appendix 5). Disagreements between reviewers at
and article levels to identify studies that would
each stage of the process were resolved through
answer the posed research question.
identifying the source of conflict, reevaluating the
Research articles were included for review if they
study, and discussing the disagreement. If consensus
met the following criteria:
could not be reached between the two parties, a third

The study was written in English; reviewer was consulted.

The study subjects/patients had a diagnosis of The quality of each article was determined using
CTS the 24 evaluation criteria of the SEQES. These 24

The study evaluated one or more physiotherapeu- criteria are divided into seven domains: study
tic interventions that could be used by physio- question, study design, subjects, intervention, out-
therapists/hand therapists/occupational therapists comes, analysis, and recommendations. Each crite-
according to their scope of practice rion was scored out of two, for a possible maximum

April–June 2004 211

score of 48. Based on the cumulative score of each
study, a classification system was devised to rank the
studies as low, moderate, or high quality:
Low quality: scores 1–16
Moderate quality: scores 17–32
High quality: scores 33–48
Sackett’s Levels of Evidence23 are based on study
design and other quality criteria. There are five levels
ranging from level 1 (ie, high-quality randomized,
controlled trial [RCT]) to level 5 (ie, expert opinion).
Grades of recommendation for a specific intervention
are based on the levels of evidence of the evaluated
studies. There are four grades of recommendation
ranging from grade A (ie, consistent level 1 studies)
to grade D (ie, level 5 evidence, inconsistent or
inconclusive studies) (Appendix 5).
Data Extraction
The reviewers who appraised each study also
extracted data from the article using a component of
the SEQES. The following information was extracted
from each included article as available:

Participant demographics (age, gender, duration
of symptoms; comorbidity/important covariates,
etiology, method of confirmation of CTS);

Intervention (type, frequency, intensity, duration,
treatment schedule);

Sample size and treatment allocation;

Outcome measures (primary, secondary; evalua-
tion schedule);

Results—outcomes (absolute change and level of
significance);

Risk factors for nonresponse or complications/
side effects;

Time elapsed for return to work/function.
This information was summarized in tables orga-
nized by intervention type (Tables 1–9). Abbrevia-
tions used are in Appendix 3.
RESULTS
Search and Selection of Studies
Two thousand twenty-seven articles were identi-
fied from the literature search. After evaluation of the
title of these articles, 345 articles met the inclusion
criteria. Based on evaluation of abstracts, 69 articles
were included for critical appraisal. Of these, 44 were
excluded (Appendix 4) during evaluation of the
article based on the previously established exclusion
criteria. Thus, 24 primary studies were included in
the systematic review and recommendations were
based on the results of these studies.
212 JOURNAL OF HAND THERAPY
Recommendations
Splinting
Nine studies evaluated splinting as an intervention
for CTS (Table 1).4,24–31 Based on these studies, the
following recommendations were made.
Grade B Recommendations

Night splinting alone reduces symptom severity,
CTS severity (based on nerve conduction testing),
and increases function and subjective global
improvement more than no treatment (level of
evidence = 2b: 1 low-quality RCT, SEQES
score = 36).24

Full-time splinting improves median nerve con-
duction more than night splinting alone (level of
evidence = 2b: 1 low-quality RCT, SEQES
score = 29).25

Full-time splinting does not reduce symptom
severity or improve function more than night
splinting alone (level of evidence = 2b: 1 low-
quality RCT, SEQES score = 29).25

Surgery improves symptoms (decreases paresthe-
sia and symptom severity), nerve conduction,
severity of main complaints, and treatment success
rate (based on self-reported general improvement)
more than night splinting alone (level of eviden-
ce = 2b: 1 low-quality RCT, SEQES score = 38).4
Grade C Recommendations

Night splinting plus splinting during aggravating
daytime activities improves symptoms (numb-
ness, pain, and tingling) more than no treatment
(level of evidence = 4: 2 low-quality cohort stud-
ies, SEQES score = 28).26,31

Splinting of the wrist in a neutral position
improves overall symptoms and nighttime symp-
toms more than splinting in 208 of wrist extension
(level of evidence = 4: 1 low-quality cohort,
SEQES score = 24).27

Volar cock-up splints and ulnar gutter splints are
equally effective in improving symptoms and
function (level of evidence = 4: 1 low-quality
cohort, SEQES score = 24).28

Splinting decreases symptoms of CTS in pregnant
women (level of evidence = 4: 2 case series, SEQES
score = 14).29,30

Splinting increases hand strength (grip and pinch)
in pregnant women (level of evidence = 4: 1 case
series, SEQES score = 14).30
Ultrasound
Two studies evaluated the effects of ultrasound on
patients with CTS (Table 3).32,33 The following
recommendations were based on these low-quality
RCTs.
 TABLE 1. Summary of Evidence on Splinting*
Subjects Intervention Evaluation
Results (statistically
Author/ No. of Subjects Mean Symptoms Measurement significant LOE
Year (no. of hands) Age (duration) Type Frequency Duration Outcome Measures Schedule at p\0.05) and QS

Gerritsen Rx: 89 49 Rx: Splint Nightly with 6 wks Primary: general Baseline Between groups: 2b
et al., C: 87 C: Sx optional minimum improvement 1 month success rate: C > Rx 38
20024 day wear Sleep 3 mos at 3, 6, 12, and 18 mos
Severity of main 6 mos Sleep
complaint (night 12 mos improvement: Rx > C
and day) Secondary: 18 mos at 1 month; C > Rx at
Symptom Severity (SSS) 6 mos
Function (FSS) Severity Improvement in severity
of complaints Nerve of main complaint:
conduction (DSL, DML) C > Rx from 3, 6, 12,
and 18 mos
Symptom severity
improvement: C > Rx
from 3, 6, 12, and 18 mos
Improvement
in function: C > Rx
at 3 and 6 mos
Sensory nerve
conduction (to index
finger) improvement:
C > Rx at 12 mos
Manente Rx: 42 Rx: 46 Rx: Night Nightly 4 wks Primary: symptoms Baseline Within group: no 2b
et al., C: 41 C: 41 Brace and function (BCTQ) 2 wks significant differences 36
200124 C: No Rx. Impression of (during Between groups: BCTQ:
change (SGICQ) Rx) Rx > C at 2 and 4 wks
Secondary: nerve 4 wks Impression of Change:
conduction (DML, (end Rx > C at 4 wks
SCV, SNAP) of Rx) Decrease of severity:
Severity Rx > C at 4 wks
Walker 17 (24) 60 Rx: Full-time Night + 6 wks Symptoms and Baseline Within group: combined 2b
et al., splint C: daily function (BCTQ). Immediately Rx and C: # symptom 29
2000.25 Night splint activities Nerve conduction post-Rx severity, " function,
(MDL, SDL) improved sensory
nerve conduction
Between groups: nerve
conduction (motor)
improvement: Rx > C
Symptom severity
or function: no
significant differences
Li et al., 22 (29) 45 42 wks Splint + Night +/or 12 wks Symptom Severity Baseline 1: Within group: Symptom 4
199926 education day during (SSS) 1–2 wks severity: # at 2 and 28
+ wrist repetitive/extreme Function (FSS) pre-Rx 10–12 wks
exercises wrist motion Baseline 2: Function:
2x/day if immediately " at 10–12 wks
day splinting pre-Rx 2 wks
10-12 wks
Burke 59 (90) Rx: 25 Rx: Neutral Night 2 mos Symptoms 2 wks Between groups: overall 4
et al., mos splint Improvement 2 mos symptom improvement: 24
199427 C: 28 mos C: 200 Ext. (overall, Rx > C at 2 wks
splint night, day) Night symptom improvement:
Rx > C at 2 wks
Daytime symptom relief:
Rx = C at 2 wks
Between group analyses not
conducted at 2 mos
Dolhanty, Rx: 6 (6) Rx: 49 Rx: 30 Rx: splint Rx: night 1 week Pain Baseline Baseline: Rx = C 4
198631 C: 6 (6) C: 52 wks C: No splint and during Numbness 1 week 1 week: Pain: Rx\C 21
C: 26 wks activities Tingling Numbness: Rx\C
C: N/A Morning Tingling: Rx\C
stiffness Morning stiffness: Rx = C
Daniel and 4 Rx1: Volar 8 wks Symptoms Between groups: 4
Paul, Cock-up Alternated Function Improvement in 17
200028 Splint between symptoms or
Rx2: ulnar Rx1 and function: no
gutter Rx2 every significant
splint 2 wks differences
Courts, 82 (135) Rx: splint Grip strength Pinch Within group: Grip 4
199530 pregnant strength Symptoms strength " Pinch 14
women strength "
Symptoms #
Ekman- 56 (100) 29 4 wks Night splint Night 2 wks Presence of symptoms Baseline. Within group: 4
Ordenberg pregnant Subjective: night 2 wks. 82% 14
et al., women pain Paraesthesia symptom-free
198729 Objective: Light touch
Two-point
discrimination
Opponens tone

*See Appendix 3 for a list of abbreviations.

April–June 2004 213

 TABLE 2. Summary of Evidence on Ultrasound*
Subjects Intervention Evaluation

No of Results
Subjects Mean Measure- (statistically LOE
Author/ (no. of Age Symptoms Outcome ment significant and
Year hands) (yrs) (duration) Type Frequency Duration Measures Schedule at p\0.05) QS
Ebenbichler 45 51 Mean Rx: Daily 2 wks + Primary: Baseline Between groups: 2b 34
et al., Bilateral 8 mos US 1 MHz, 5x/wk 5 wks Symptoms 2 wks Symptoms
199832 W/cm2, + 2x/wk Sensation 7 wks improvement:
pulsed 15 min Nerve 6 mos Rx > C at 2
1:4 20 treatments conduction wks, 7 wks,
C: sham US Secondary: 6 mos
grip Sensory loss:
strength Rx\C at 2 wks,
Pinch 7 wks, 6 mos
strength Improvement
General in nerve
improvement conduction
velocity:
Rx > C at 2 wks,
7 wks, 6 mos
Grip strength
improvement:
Rx > C at 7 wks,
6 mos
Pinch strength
improvement:
Rx > C at 6 mos
General
improvement:
Rx > C at 7 wks
Oztas 18 $ (30) 52 Mean Rx1: 5x/wk 2 wks Pain Night Within group: 2b 33
et al., 84 mos US 3 MHz, 5 min 10 pain or Rx1: # pain,
199833 1.5 W/cm2 Treatments paraesthesia # night pain,
Rx2: Waking # waking
US 3 MHz, Nerve Rx2: # pain,
0.8 W/cm2 conduction # Night pain,
C: sham US # waking C:
# pain, # Night
pain, # waking
Between
groups: no
significant
differences
*See Appendix 3 for a list of abbreviations.

Grade B Recommendations Nerve Gliding Exercises

Deep, pulsed ultrasound in 20 treatments for 15
minutes decreases symptoms (decreases pain and
paresthesia), reduces sensory loss, and improves
median nerve conduction and strength (pinch,
grip) more than sham ultrasound (level of eviden-
ce = 2b: 1 low-quality RCT, SEQES score = 34).32

Superficial, continuous ultrasound in 10 treat-
ments for five minutes decreases pain, but is no
more effective than sham ultrasound (level of
evidence = 2b: 1 low-quality RCT, SEQES
score = 33).33

Superficial, continuous ultrasound in 10 treat-
ments for five minutes does not improve median
nerve conduction (level of evidence = 2b: 1 low-
quality RCT, SEQES score = 33).33
Two studies assessed nerve gliding exercises in the
treatment of patients with CTS (Table 3).34,35 These
recommendations were made based on the results of
these RCTs.
Grade B Recommendations

Nerve gliding exercises relieve pain more than no
treatment (level of evidence = 2b: 1 low-quality
RCT, SEQES score = 34).34

Nerve gliding exercises decrease pain and increase
active range of motion of wrist flexion and
extension (level of evidence = 2b: 1 low-quality
RCT, SEQES score = 34).34

214 JOURNAL OF HAND THERAPY

 TABLE 3. Summary of Evidence on Gliding Exercise*
Subjects Intervention Evaluation
Results
Author/ No of Mean (statistically LOE
Year Subjects Age Symptoms Outcome Measurement significant and
(no. of hands) (yrs) (duration) Type Frequency Duration Measures Schedule at p\0.05) QS

Tal-Akabi 21 47 2.3 yrs Rx1: Neuro- Mobilization Pain Pain Baseline Within Group: 2b
et al., Sx wait dyanamic grade relief post-Rx Rx1: # pain, " AROM 34
200034 list mobilization dependent Function flexion and extension
Rx2: carpal bone on AROM Rx2: # pain, " AROM
mobilization symptoms (wrist) extension
+ flexor ULTT Between Groups:
retinaculum Sx pain relief:
stretch Rx1 > C; Rx2 > C;
C: no Rx Rx1 = Rx2
Akalin 28 (36) 52 Rx: tendon 5 tendon 4 wks Phalen’s Baseline Within Group: 2b
et al., gliding gliding Sign 8 wks Rx: # Phalen’s and 27
200235 exercises + exercises; Tinel’s sign follow Tinel’s Sign, improved
nerve 6 nerve 2-point up 2-point discrimination,
gliding gliding discrimination " grip and pinch strength,
exercises exercises Grip strength # symptom severity,
+ splinting 5 sec per Pinch " function
C: splinting exercise, strength C: # Phalen’s
10 reps, Symptom and Tinel’s sign, " grip &
5x/day Severity pinch strength,
Nightly (SSS) # symptom severity, "
splinting Function function
(FSS) Between
Groups: pinch
strength improvement:
Rx > C

*See Appendix 3 for a list of abbreviations.

Addition of Nerve and Tendon Gliding Exercises to Grade B Recommendations

Splinting

Single session of brief magnetic therapy and sham
treatment both decrease pain for CTS. Single
Grade B Recommendations session of brief magnetic therapy does not de-

Nerve and tendon gliding exercises plus splinting crease pain more than sham treatment (level of
improve pinch grip strength more than splinting evidence = 2b: 1 low-quality RCT, SEQES
alone (level of evidence = 2b: 1 low-quality RCT, score = 36).36
SEQES score = 27).35
Prolonged magnetic therapy in wrist support

Nerve and tendon gliding exercises plus splinting wraps improves symptoms (numbness and tin-
do not reduce median nerve dysfunction (Phalen’s gling) and median nerve conduction more than
sign, Tinel’s sign), symptom severity, or improve sham treatment (level of evidence = 2b: 1 low-
function, grip strength or sensation (two-point quality RCT, SEQES score = 25).37
discrimination) more than splinting alone (level of
evidence = 2b: 1 low-quality RCT, SEQES Low-level Laser
score = 27).35
Two studies assessed the effects of low-level laser
Grade C Recommendations therapy (Table 5).38,39 Based on these studies, the
following recommendation was made.

Nerve and tendon gliding exercises plus splint-
ing reduce median nerve dysfunction (Phalen’s Grade C Recommendations
sign, Tinel’s sign) and symptom severity, and
improve sensation (two-point discrimination),
Low-level laser reduces symptom severity (de-
strength (pinch and grip), and function (level creases pain, numbness, and tingling) and im-
of evidence = 2b: 1 low-quality RCT, SEQES proves function and median nerve conduction
score = 27).35 (level of evidence = 4: 1 low-quality cohort,
SEQES score = 25).38

Magnetic Therapy Note: Results of another study show trends in

changes of paresthesia and nerve conduction in
Two studies evaluated the effects of magnetic the same direction as the above recommendation;
therapy on patients with CTS (Table 4).36,37 The however, these trends were not statistically signifi-
following recommendations were based on these cant (level of evidence = 4: 1 case series, SEQES
two RCTs. score = 14).39

April–June 2004 215

 TABLE 4. Summary of Evidence on Magnetic Therapy*
Subjects Intervention Evaluation Results
(statistically LOE
Author/ No of Subjects Mean Symptoms Outcome Measurement significant and
Year (no. of hands) Age (yrs) (duration) Type Frequency Duration Measures Schedule at p\0.05) QS

Carter, 30 Rx: 51 Rx: magnetic 1 session 45 min Pain Baseline Within Group: 2b
200236 C: 49 therapy 1000 15 min Rx: # Pain from 36
gauss 30 min baseline to post-Rx
C: sham 45 min C: # pain from
magnetic 2 wks baseline to post-Rx
therapy Between groups:
no differences at
any
measurement time
Weintraub 6 (8) $: 63 37 mos Rx: wrist 1 mo Rx or 24 hr/day Pain Baseline Between groups: 2b
and Cole, #: 75 (3–108 mos) support wrap C, then constant Burning 4 wks numbness 25
200037 350 gauss 1 mo contact Numbness + 8 wks and tingling
magnetized alternate tingling improvement:
CNTL: condition Nerve Rx > C
wrist support conduction Nerve conduction
wrap with improvement:
sham magnets Rx > C

*See Appendix 3 for a list of abbreviations.

Yoga Acupuncture

One RCT evaluated the effects of yoga exercise on
CTS symptoms (Table 6).40 Based on this study, three
recommendations were made.
Grade B Recommendations

Yoga reduces median nerve dysfunction (Phalen’s
sign) more than splinting (level of evidence = 2b: 1
low-quality RCT, SEQES score = 34).40

Yoga does not decrease pain or increase grip
strength more than splinting (level of eviden-
ce = 2b: 1 low-quality RCT, SEQES score =
34).40
Grade C Recommendations

Yoga decreases pain and increases grip strength
(level of evidence = 2b: 1 low-quality RCT, SEQES
score = 34).40
Manual Therapy
Two studies evaluated the effects of manual
therapy on subjects with CTS (Table 7).34,41 The
following recommendations were based on these
studies.
One study examined the effects of acupuncture on
symptoms of CTS (Table 8).42 The following recom-
mendation was based on this case series.
Grade D Recommendations

Inconclusive results for the effects of acupuncture
on pain, discomfort and grip strength (level of
evidence = 4: 1 case series, SEQES score = 15).42
Combined Therapies
Four studies evaluated the effects of combination
therapies on patients with CTS (Table 9).7,43–46 The
following recommendations were based on these
studies.
Grade B Recommendations

Combination of manual therapy, myofascial mas-
sage, ultrasound, and night splinting does not
improve nerve conduction, physical and mental
distress, or sensation more than night splinting
and nonsteroidal antiinflammatory drugs (level of
evidence = 2b: 1 low-quality RCT, SEQES
score = 37).43

Grade B Recommendations Grade C Recommendations

Carpal bone mobilization plus flexor retinaculum
stretch relieves pain more than no treatment (level
of evidence = 2b: 1 low-quality RCT, SEQES
score = 34).34
Grade C Recommendations

Carpal bone mobilization plus flexor retinaculum
stretch decreases pain and increases active range
of motion of wrist extension (level of eviden-
ce = 2b: 1 low-quality RCT, SEQES score = 34).34

Adding gliding exercises (tendon and nerve) and
contrast bath to treatment with splinting, non-
steroidal antiinflammatory drugs, and steroid
injections decreases incidence of surgery over four
months (level of evidence = 4: 1 low-quality
cohort, SEQES score = 23).7

Combination of laser acupuncture and transcuta-
neous electrical nerve stimulation, supplemented
with Chinese herbal medicine, moxibustion, and
needle acupuncture, decreases pain (level of
evidence = 4: 1 case series, SEQES score = 19).44

216 JOURNAL OF HAND THERAPY

 TABLE 5. Summary of Evidence on Laser Therapy*
Subjects Intervention Evaluation
Results
No. of Mean Measure- (statistically LOE
Author/ Subjects Age Outcome ment significant and
Year (no. of hands) (yrs) Symptoms Type Frequency Duration Measures Schedule at p\0.05) QS

Padua Rx: 45 11 mos Rx: low-power 10 min/session 2 wks Symptoms Baseline Within group: Rx: 4
et al., 10 (17) 45 13 mos GaAs laser 6 sessions and 1 wk Symptoms: # at 2 25
199938 C: 30 Both Wrist 3x/wk function 2 wks and 10 wks Function:
groups 830 nm (BCTQ). 4 wks " at 2 wks Sensory
minimal, 1080 mJ Nerve 10 wks nerve conduction:
mild, or per session conduction 54 wks improved at 1, 2,
moderate C: no Rx and 4 wks Motor
CTS (isolated nerve conduction:
NSAIDs) improved at 4, 10,
and 54 wks C: no
significant differences
from baseline to
posttreatment
Between groups: analyses
not conducted
Weintraub, 23 (30) 52 24 mos Low-power 15 sessions Sensation Before Within group: 4
199739 Moderate GaAs laser Treatments Nerve each resolution of 14
to severe Along median discontinued function treatment symptoms and
CTS nerve if asymptomatic After abnormal physiological
Continuous each findings: 77%
830 nm 30 mW treatment patients
Nerve function
normalization:
48% patients

*See Appendix 3 for a list of abbreviations.

Manipulation and stretching exercises, supple-
mented with ultrasound and diet modifications,
increase strength, range of motion, and decrease
pain, but does not affect task performance (level of
evidence = 4: 1 case series, SEQES score = 11).45,46
Research Quality and Levels of Evidence
Overall, the levels of evidence of the reviewed
studies ranged from 2b to 4 and the quality of these
studies ranged from 11 to 38 using the SEQES (Table
10). Specifically, studies evaluating the effectiveness
of ultrasound (SEQES score = 33–34), gliding exer-
cises (SEQES score = 27–34), yoga (score 34), and
magnetic therapy (SEQES score = 25–36) were of
higher quality. The study of acupuncture in the
treatment of CTS was rated of low quality (SEQES
score = 15). Studies examining the effects of splinting
(SEQES score = 14–38), manual therapy (SEQES
score = 11–34), laser therapy (SEQES score = 14–25),
and combined therapies (SEQES score = 11–37)
varied considerably in their quality.
After critical appraisal of all reviewed studies, each
of the 24 items on the SEQES was examined
independently. Scores from all studies were summed
for each of the 24 evaluation criteria. Total scores
were used to determine common strengths and
methodologic shortcomings of the reviewed studies
(Table 10). Six strengths (defined as SEQES items
with total item scores of 32 or more) were identified.
These included: 1) thorough background information
cited to establish rationale for the research question,
2) consideration of patient status at multiple time
points, 3) prospective data collection, 4) well-defined
inclusion/exclusion criteria, 5) well-described appli-
cation of intervention(s) according to established
principles, and 6) support of conclusions by study
results (Table 10 and Appendix 2).
Common study flaws (defined as SEQES items
with total item scores of 16 or less) were also
identified (Table 10). These included: 1) inadequate
blinding of treatment providers, 2) lack of indepen-
dent evaluation of outcome measures, 3) inadequate
sample size/enrollment or lack of sample size
calculation, 4) potential for treatment provider
biases, and 5) lack of consideration of clinical and/
or practical significance of results (Table 10 and
Appendix 2).
Agreement between Reviewers
The reviewers disagreed on the level of evidence
rating of five studies.26,27,31,32,45 Most of these
disagreements26,27,32 were between two reviewers
(JH and DT). These reviewers also disagreed with
other reviewers (LD and MM) on the levels of
evidence for the remaining two studies.31,45 The
disagreements were mostly due to reading error or
differences in interpretation. The differences in
interpretation largely concerned criteria for low-
quality studies based on Sackett’s Levels of Evi-
dence.23 All disagreements were resolved with
a collaborative discussion among group members,

April–June 2004 217

 TABLE 6. Summary of Evidence on Yoga*
Subjects Intervention Evaluation
Results
No of Mean (statistically LOE
Author/ Subjects Age Symptoms Outcome Measurement significant and
Year (no. of hands) (yrs) (duration) Type Frequency Duration Measures Schedule at p\0.05) QS

Garfinkel Rx: Rx: 49 Rx: Yoga Rx: 8 wks Pain Baseline Within group: 2b
et al., 26 (35) C: 49 C: splint 60–90 min, Grip strength 8 wks Rx: # pain, 34
199840 C: 20 (32) 2x/wk Tinel’s sign " grip
C: not Phalen’s sign strength
reported Disturbed sleep Between groups:
Nerve conduction Phalen’s sign
improvement: Rx > C

*See Appendix 3 for a list of abbreviations.

TABLE 7. Summary of Evidence on Manual Therapy*

Subjects Intervention Evaluation
Results
No of Mean Measure- (statistically LOE
Author/ Subjects (no. Age Symptoms Outcome ment significant and
Year of hands) (yrs) (duration) Type Frequency Duration Measures Schedule at p\0.05) QS

Tal-Akabi 21 47 2.3 yrs Rx1: neuro- Mobilization Pain Baseline Within group: 2b
and Sx wait dyanamic grade Pain relief Post-Rx Rx1: # pain, 34
Rushton, list mobilization dependent Function " AROM
200034 Rx2: on symptoms AROM: flexion and
carpal bone wrist flexion/ extension Rx2:
mobilization + extension # pain , " AROM
flexor ULTT extension
retinaculum Surgery Between
stretch groups: Pain
C: no Rx relief: Rx1 > C;
Rx2 > C;
Rx1 = Rx2
Manente 71 (112) 54 13 mos Carpal tunnel One Symptoms Within group 4
et al., relief maneuver treatment Nerve trends: 11
199941 Digits session conduction elimination
3 and 4 (SNC and of symptoms:
stretches DML) 23% patients
Phalen’s Improvement
test of paresthesia:
position 77% patients
Within
group: no
significant
differences

*See Appendix 3 for a list of abbreviations.

and consensus was reached without requiring a third
reviewer’s participation.
DISCUSSION
Recent systematic reviews investigating conserva-
tive treatment for CTS only considered RCTs.21,22
Gerritsen et al. reviewed fourteen studies in English,
German, French, or Dutch and included evaluations
of drug therapy.21 O’Connor et al. reviewed 21
studies in English, German, or Turkish and also
included studies of drug therapies (nonsteroidal
antiinflammatory drugs, steroids, diuretics, and
vitamin B6).22 The present systematic review adop-
ted a broader approach by including all clinical
studies of hand therapy interventions for CTS
irrespective of study design. This resulted in the
inclusion of 24 studies and allowed evaluation of
treatments that had not been previously evaluated in
a RCT but that still have evidence to support or refute
their clinical use. Consequently, best available evi-
dence for a broad range of conservative therapies
could be elucidated.
Splinting
Splinting was supported by two level 2b stud-
ies24,25 and three level 4 studies.26,30,31 Of interest,
different types of splints28 and various angles of
immobilization27 were found effective in the treat-
ment of CTS. Clinically, this could reflect the greater

218 JOURNAL OF HAND THERAPY

 TABLE 8. Summary of Evidence on Acupuncture*
Subjects Intervention Evaluation
Results
No of Mean (statistically LOE
Author/ Subjects Age Symptoms Outcome Measurement significant and
Year (no. of hands) (yrs) (duration) Type Frequency Duration Measures Schedule at p\0.05) QS

Chen, 36 54 2 mos–35 Acupuncture 30 min/site Pain 1–3 days Within-group 4

199042 Previous yrs PC-7 (Daling), 4–23 treatments relief and after treatment trends (no 15
Sx: 14 No PC-6 (Neiguan) 2x/wk—3–4x/wk discomfort session statistical
history sites (alternating days) Grip strength Before analyses):
of Sx Supplement: Dependent on each treatment # pain &
3-Hz electro- symptom severity After each discomfort
acupuncture treatment " grip
strength

*See Appendix 3 for a list of abbreviations.

importance of wrist immobilization over use of
specific splint design or splinting angle, provided
that the carpal tunnel is not in a compressed position.
There was also evidence in support of splinting as
a treatment for pregnant women with CTS.29,30
However, due to these studies’ design (case series),
it was unclear whether symptom reduction and/or
resolution were due to splint use or the natural
course of CTS in pregnant women.
The remaining study compared splinting and
surgical treatment and found that surgery was
generally more effective than splinting.4 Two con-
founds might have affected this result. First, Gerrit-
sen et al.’s treatment parameters could have
minimized the positive effects of splinting.4 Subjects
in this study wore splints during the night and some
subjects wore noncustomized splints. Evidence,
however, suggests that custom splints promote better
compliance and results,47 and full-time splinting
improves median nerve conduction more than night
splinting alone.25 Second, subjects who underwent
surgery were absent from work during the study.
Work activities might have required use of hands and
wrists in positions that compress the carpal tunnel,
potentially exacerbating symptoms of CTS and
affecting the course of the disease. Thus, absence
from work could have conferred an advantage to
subjects in the surgical treatment group.
Ultrasound
Ultrasound was supported by a level 2b study32
but refuted by another level 2b study.33 These
findings are generally consistent with Gerritsen
et al.’s and O’Connor et al.’s systematic reviews.21,22
However, the conclusions drawn from these studies
by Gerritsen et al. and O’Connor et al. were different
from the present review’s recommendations. Gerrit-
sen et al. concluded that there was conflicting
evidence regarding the effectiveness of ultrasound,
whereas O’Connor et al. considered the two studies
sufficiently homogeneous and pooled the results,
concluding that there were no significant short-term
benefits.21,22
The present systematic review considered the two
ultrasound studies separately because their treat-
ment parameters were different and likely targeted
different tissues with different physiological mecha-
nisms of action. Ebenbichler used pulsed ultrasound
at 1 MHz, whereas Oztas used continuous ultra-
sound at 3 MHz.32,33 Pulsed ultrasound at lower
frequencies would promote mechanical effects on
deep tissues, whereas continuous ultrasound at
higher frequencies would promote thermal and
mechanical effects on superficial tissues.48 Further-
more, subjects in the study by Oztas et al. had a mean
symptom duration of 84 months and likely had more
severe CTS than subjects in the study by Ebenbichler
et al. whose mean symptom duration was eight
months.32,33
Nerve Gliding Exercises
Nerve gliding exercises were supported by two
level 2b studies.34,35 These studies were also re-
viewed by O’Connor et al., but not by Gerritsen
et al.21,22 The conclusions by O’Connor et al.,
however, differed from the recommendations of this
review.22 First, O’Connor et al. stated that there was
no significant effect of neurodynamic mobilization
on CTS symptoms, whereas the present review
concluded that neurodynamic mobilization relieved
pain more effectively than no treatment.34 In the
original article, Tal-Akabi and Rushton reported
statistically significant differences between their
three treatment groups but did not perform post-
hoc analyses to determine which of the groups were
statistically different.34 The authors of the present
review performed these post-hoc analyses from the
data of Tal-Akabi and Rushton’s study and were able
to identify specific group differences. These results
(Table 3) were used in the development of the present
recommendations and explain the discrepancy be-
tween the present conclusions and those of O’Connor
et al.22

April–June 2004 219

 TABLE 9. Summary of Evidence on Combined Therapies*
Subjects Intervention Evaluation
Results
No. of Mean (statistically LOE
Author/ Subjects Age Symptoms Outcome Measurement significant and
Year (no. of hands) (yrs) (duration) Type Frequency Duration Measures Schedule at p\0.05) QS

Davis 91 Rx: 38 Rx: HVLAT + Rx: 22 visits 9 wks Nerve Baseline Within 2b
et al., (149) C: 36 myofacial - 3x/wk x 2 conduction 9 wks group: " 37
199843 massage + wks, 2x/wk Physical 13 wks nerve
US + night x 3 wks, distress (CTOA-P) conduction
splint 1x/wk x Mental distress velocity, #
C: night 4 wks (CTOA-M) CTOA-P, #
splint + Rx per visit Vibrotactile CTOA-M,
NSAID variable sensation improved
US: 1 MHz, (vibrometric sensation
1–1.5 Wcm2, threshold) Between
50% pulsed, Function (HAND) groups:
5 min (50% Health status no significant
of visits) (SF-36) differences?
C: 11 visits
Rozmaryn 197 Rx: tendon 11 exercises, 4 mos Number Within Between 4
et al., (240) and nerve 5 reps, requiring 4 mos groups: 23
19987 gliding 3–5x/day surgery. surgery
exercises + 4 min incidence:
contrast bath + warm + 1 Rx\C
splinting + min cold,
NSAIDs + 2x/day
steroid injec-
tions
C: splinting +
NSAIDs +
steroid injections
Branco 31 55 24 mos Rx: laser 45 min, 4-5 wks Pain Baseline Within 4
and (36) Previous acupuncture + 3x/wk 12–15 3–4 weeks group: # 19
Naeser, unsuccessful TENS treatments (immediately pain from
199944 Rx for Supplement: post baseline to
pain relief Chinese treatment) post-Rx
herbal medicine,
moxibustion,
laser +/or
needle
acupuncture
Bonebrake Rx: 38 32 C: B CTS Rx: Hard tissue Average: 36 Average: Anthropometry Baseline Within group: 4
et al., CNTL: manipulation + treatments 229 days Strength: grip, Post-Rx no significant 11
1990,45 13 soft tissue Average pinch, pronation, 6 mos differences in
199346 manipulation + during supination anthropometric
stretching follow EMG: radialis and measures
exercises up: 9 ulnaris muscles " grip and
Supplement treatments ROM: wrist pinch strength
(some subjects): and forearm post-Rx and
US +/or diet Task performance at 6 mos
modifications Pain (PAD scale) " supination
strength
post-Rx
" EMG values
during maximal
grip task
post-Rx and
at 6 mos
" EMG values
for during
assembly task
at 6 mos
" ROM post-Rx
# radial deviation
and " wrist
flexion and
extension at
6 mos
No significant
differences in
task performance
# PAD post-Rx
and at 6 mos

*See Appendix 3 for a list of abbreviations.

220 JOURNAL OF HAND THERAPY

TABLE 10. Research Quality (SEQES scores) and Sackett’s Level of Evidence (LOE) Summary for 24 Included Articles
SEQES Evaluation Criteria

Citation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 TOTAL LOE

35
Akalin et al., 2002 2 2 2 1 1 1 0 0 1 2 0 2 2 0 2 1 1 1 1 0 1 2 1 1 27 2b
Bonebrake et al, 1990,45 1 1 1 1 0 0 0 1 0 1 0 0 0 0 0 1 1 0 1 0 1 0 0 1 11 4
199346
Branco and Naeser, 199944 1 1 1 2 0 0 0 0 1 0 0 2 2 0 0 1 0 1 1 0 2 1 1 2 19 4
Burke et al., 199427 1 2 1 2 2 1 1 0 1 1 0 1 1 1 2 1 0 1 1 1 1 0 1 1 24 4
Carter et al., 200236 1 2 2 2 2 2 1 1 1 2 2 0 2 2 2 1 0 1 2 1 2 0 1 2 34 2b
Chen, 199042 1 0 1 1 0 1 1 0 1 1 0 1 1 0 0 1 1 2 0 0 0 0 1 1 15 4
Courts, 199530 1 0 2 2 0 0 0 0 2 2 0 0 1 0 0 1 0 1 0 0 1 0 0 1 14 4
Daniel and Paul, 200028 2 1 1 2 0 1 0 0 0 0 0 2 1 1 1 1 0 0 1 0 0 2 0 1 17 4
Davis et al., 199843 1 2 2 2 2 1 1 2 2 2 2 1 2 0 2 2 2 1 2 2 1 0 1 2 37 2b
Dolhanty, 198631 2 2 1 1 0 1 1 0 1 1 0 2 1 0 2 1 0 1 1 0 1 1 0 1 21 4
Ebenbichler et al., 199832 1 1 2 2 2 2 2 2 1 2 1 0 2 2 2 1 1 1 1 1 2 0 1 2 34 2b
Ekman-Ordenberg et al., 1 0 2 1 0 1 1 0 1 0 0 2 0 1 0 1 1 0 0 0 0 1 0 1 14 4
198729
Garfinkel et al., 199840 2 1 2 2 2 1 1 2 2 2 0 1 2 0 2 1 1 1 2 2 2 1 0 2 34 2b
Gerritsen et al., 20024 2 2 2 2 2 1 1 2 2 2 2 1 1 1 2 1 1 2 2 1 2 2 1 1 38 2b
Li et al., 199926 2 0 2 2 0 0 1 0 0 2 1 1 2 0 1 2 1 2 2 2 1 1 1 2 28 4
Manente et al., 200124 2 2 2 2 2 1 1 0 2 2 0 2 2 0 2 2 2 1 2 2 1 1 1 2 36 2b
Manente et al., 199941 0 0 0 1 0 1 0 0 1 1 0 2 0 0 0 0 0 0 1 1 0 2 0 1 11 4
Oztas et al., 199833 2 2 2 2 1 1 1 0 1 2 0 2 2 1 2 1 2 1 1 1 2 2 0 2 33 2b
Padua et al., 199938 2 1 2 2 0 0 0 0 1 2 0 1 2 0 1 2 1 2 1 0 1 1 1 2 25 4
Rozmaryn et al., 19987 2 1 1 0 0 1 1 1 0 2 0 0 2 0 2 2 1 1 1 1 1 0 1 2 23 4
Tal-Akabi and 2 2 2 2 2 1 1 2 1 2 0 2 1 0 2 1 2 1 2 0 1 2 1 2 34 2b
Rushton,200034
Walker et al., 200025 2 2 2 2 2 1 0 0 1 2 0 1 2 0 2 2 0 1 2 0 1 1 0 2 28 2b
Weintraub, 199739 1 0 2 1 0 0 0 0 0 0 0 2 0 0 0 1 1 1 1 0 0 0 2 1 13 4
Weintraub and Cole, 200037 2 2 1 2 1 2 0 0 1 1 0 1 1 1 1 1 1 1 1 2 1 1 0 1 25 2b
Totals 36 29 38 39 21 21 15 13 24 34 8 29 32 11 30 29 20 24 29 17 25 21 15 36

Another difference between the results of the the wrist more than the bracelets used by Carter et al.
present review and those of O’Connor et al. concerns Although Weintraub and Cole’s positive findings
the study by Akalin et al.35 O’Connor et al.’s review supported continuous long-term use of lower
found a significant effect of nerve and tendon gliding strength magnets, the effectiveness of magnetic
exercises on two-point discrimination, whereas the therapy alone is equivocal due to the potential
present review concluded that the addition of nerve splinting effect from concurrent use of wrist supports.
and tendon gliding exercises to splinting improved
pinch strength but had no effect on two-point
Laser Therapy
discrimination compared with splinting alone. Un-
like Tal-Akabi and Rushton’s study, this difference Laser therapy was supported by one level 4
was not due to additional statistical analyses of the study.38 A second level 4 study39 also concluded in
available data. favor of laser therapy but did not conduct appropri-
ate data analysis to support this claim. As a result of
Magnetic Therapy shortcomings in research design and/or statistical
analyses, these studies provided limited evidence
Magnetic therapy was supported by one level 2b regarding the effectiveness of low-power laser
study,37 but was shown ineffective by a second level therapy. These studies were not reviewed by Gerrit-
2b study.36 Gerritsen et al. did not review either study, sen et al. or O’Connor et al.21,22
whereas O’Connor et al. only included the study by
Carter et al.21,22,36 These studies of magnetic therapy Yoga
differed in treatment parameters and outcomes
measured. Subjects in Carter et al.’s study, which Yoga exercises were supported by one level 2b
evaluated pain, used 1,000-gauss magnets for one 45- study.40 This finding generally agreed with the
minute session, whereas participants in Weintraub results of the reviews by Gerritsen et al. and
and Cole’s study, which assessed sensation and nerve O’Connor et al.21,22 Biweekly 60- to 90-minute hatha
conduction, wore 350-gauss magnets all day for one yoga sessions for eight weeks improve symptoms in
month. Moreover, Weintraub and Cole used wrist people with CTS. Although treatment with yoga
support wraps to maintain constant magnet contact, decreased signs of median nerve dysfunction more
whereas Carter et al. used wrist bracelets.36,37 Thus, it than splinting, these exercises did not improve grip
is possible that the support wraps used in Weintraub strength or decrease pain more than splinting
and Cole’s study acted as a splint and immobilized alone.40 Practical implications of these results would

April–June 2004 221

be the extent to which yoga’s effects on median nerve
function translate to improved functional abilities
(eg, holding a cup). Also, the economics of treatment
with yoga versus splinting for predominantly similar
benefits would influence the choice of therapies.
Manual Therapy
Manual therapy was supported by two studie-
s—one level 2b34 and one level 4 study.41 Gerritsen
et al. did not review either study and O’Connor et al.
reviewed only Tal-Akabi and Rushton’s study, with
similar conclusions to the present review.21,22 These
studies suggested that treatment effectiveness could
be related to specific manual therapy techniques.
Carpal bone mobilization combined with flexor
retinaculum stretch effectively relieved pain,34 but
carpal tunnel relief maneuver with stretches of digits
three and four did not significantly change nerve
conduction.41
Acupuncture
Although one level 4 study by Branco and Naeser44
supported the use of laser acupuncture in combina-
tion with transcutaneous electrical nerve stimulation,
a second level 4 study by Chen42 was inconclusive
regarding the benefits of acupuncture alone. Neither
study was included in the systematic reviews by
Gerritsen et al. or O’Connor et al.21,22 The subjects in
Branco and Naeser’s study were also treated with
Chinese herbal medicine, moxibustion, and needle
acupuncture.44 Thus, benefits of treatment could not
be attributed to acupuncture alone. Despite positive
trends reported in Chen’s study, its lack of statistical
analyses prevented any firm conclusions of treatment
effects.42 Overall, the available evidence supporting
acupuncture treatment for CTS is limited.
Methodologic Limitations
This systematic review had three main methodo-
logic limitations with respect to its search strategy
and inclusion criteria. First, hand-searches for other
published or unpublished studies in reference lists,
conference proceedings, or abstracts were not con-
ducted because of time constraints. Second, also
because of time and resource limitations, researchers
and authors were not contacted to inquire about
recent unpublished studies. Third, only articles
published in English were included because the
reviewers were only fluent in written English and
funding did not allow for the use of translators.
These limitations have the potential to introduce
publication biases into the review. For example,
published studies and English studies may have
a stronger tendency to present only positive results,49
whereas studies reported only in abstract form are
222 JOURNAL OF HAND THERAPY
more likely to have statistically insignificant results
or less rigorous study designs.50
Future Research
Suggested directions for future research include
the following four areas. First, more high-quality
research to confirm and expand on current knowl-
edge of hand therapy treatments for CTS should be
conducted. More specifically, interventions with
stronger evidence of effectiveness (eg, splinting,
deep pulsed ultrasound, nerve gliding exercises)
could be compared to evaluate their relative benefits.
Therapies with moderate or weaker evidence of
effectiveness (eg, laser therapy, acupuncture) could
be further evaluated with RCTs or cohort
studies using a placebo comparison group whenever
possible.
Second, the natural history and occupational/
environmental influences on the course of CTS
should be considered. Rozmaryn et al. noted that
their patients with CTS had remissions and exacer-
bations of the disease, whereas some patients
experienced symptom resolution with conservative
treatment; others had progressive symptoms with
resulting chronicity.7 It can be reasoned that a better
understanding of the factors affecting the course and
severity of CTS may help identify individuals with
CTS who are more likely to benefit from conservative
treatment. Concurrently, people with CTS who are at
risk of chronicity and/or who are more likely to
benefit from surgical treatment can also be identified
and appropriately treated. Thus, future research
could systematically document client characteristics
(eg, occupation, symptom duration, comorbidities) to
identify factors related to prognosis and response to
treatment.
Third, combinations of conservative therapies to
elucidate optimal treatment programs should be
investigated. Although this review identified four
studies that evaluated combined therapies, these
studies did not compare the addition of a specific
intervention to a control combination of treat-
ments.7,43,44,51 Thus, conclusions about the benefits
of adding a specific intervention to a baseline treat-
ment program could not be drawn. To aid clinicians
in selecting an effective combination of therapies,
future research might consider investigating the
effects of combining therapies in a systematic and
evidence-based manner. For example, comparing
splinting (night) with splinting plus ultrasound
(pulsed, deep), and with splinting, ultrasound, plus
gliding exercises. The results of such studies would
better inform clinicians of effective treatment combi-
nations. Also, studies of combined therapies might
be more reflective of current hand therapy/physio-
therapy practice in which multiple treatment modal-
ities are used simultaneously.
 Fourth, the financial costs/benefits of different
effective therapies should be evaluated and com-
pared. Despite the reported high financial burden of
CTS (average cost of US $3500 per case, US $30,000 to
$60,000 per severe cases18), few researchers provided
the cost of the studied treatment(s). Because present
evidence supports the use of certain conservative
therapies (eg, splinting, ultrasound, gliding exer-
cises) for CTS, a possible direction for future research
may be to evaluate the cost-effectiveness of these
interventions. Such information should promote
fiscally responsible decision-making by those in-
volved in the care of people with CTS.
Clinical Implications
The best available evidence to date shows statis-
tically significant benefits (grade B recommenda-
tions) from splinting, ultrasound, nerve gliding
exercises, carpal bone mobilization with flexor
retinaculum stretch, and hatha yoga for people with
CTS. The evidence also indicates that the effects of
ultrasound depend on specific treatment parameters;
pulsed, deep ultrasound is effective, whereas con-
tinuous, superficial ultrasound is not. There is
limited evidence (grade C recommendation) to sup-
port the use of laser therapy and various combined
therapies. Although prolonged magnetic therapy
seems beneficial, possible splinting effects from
concurrently applied wrist support wraps con-
found results and render the evidence for magnetic
therapy inconclusive. Results from acupuncture
research are also inconclusive (grade D recommen-
dation).
Results of this systematic review suggest that there
are many conservative hand therapy interventions
that could be used in the treatment of CTS. Evidence-
based practice combines the results of research trials
with the unique presentation and needs of the
individual patient. Choosing interventions that have
proven effective in subjects who present similarly to
the patient in question will likely improve the
potential for a positive outcome. Therefore, when
applying the results of this systematic review, in-
dividual characteristics of the patient must be
considered in combination with the evidence pre-
sented.
CONCLUSION
This systematic review presents many conserva-
tive therapeutic options for hand therapists to con-
sider in the treatment of patients with CTS. The best
available evidence to date shows a significant benefit
from splinting, deep pulsed ultrasound, nerve glid-
ing exercises, carpal bone mobilization, and yoga for
people with CTS.
REFERENCES
1. Werner RA, Andary M. Carpal tunnel syndrome: pathophys-
iology and clinical neurophysiology. Clin Neurophysiol.
2002;113:1373–81.
2. Osterman A. Nonoperative carpal tunnel syndrome treatment.
Hand Clin. 2002;18:279–89.
3. Kerwin G, Williams C, Seller J. The pathophysiology of carpal
tunnel syndrome. Hand Clin. 1996;12:242–51.
4. Gerritsen AA, de Vet HC, Scholten RJ, Bertelsmann FW, de
Krom MC, Bouter LM. Splinting vs. surgery in the treatment of
carpal tunnel syndrome: a randomized controlled trial. JAMA.
2002;288:1245–51.
5. Rempel D, Evanoff B, Amadio P, et al. Consensus criteria for
classification of carpal tunnel syndrome in epidemiologic
studies. Am J Public Health. 1998;88:1447–51.
6. Nathan PA, Keniston R, Myers L, Meadows KD, Lockwood R.
Natural history of median nerve sensory conduction in ind-
ustry: relationship to symptoms and carpal tunnel syndrome
in 558 hands over 11 years. Muscle Nerve. 1998;21:711–21.
7. Rozmaryn LM, Dovelle S, Rothman ER, Gorman K, Olvey KM,
Bartko JJ. Nerve and tendon gliding exercises and the
conservative management of carpal tunnel syndrome. J Hand
Ther. 1998;11:171–9.
8. Katz JN, Simmons BP. Carpal tunnel syndrome. N Engl J Med.
2002;346:1807–12.
9. Werner RA, Armstrong T. Carpal tunnel syndrome: ergonomic
risk factors and intracarpal canal pressure. Phys Med Rehabil
Clin N Am. 1997;8:555–69.
10. Feuerstein M, Burrell L, Miller V, Lincoln A, Huang G, Berger
R. Clinical management of carpal tunnel syndrome: a twelve-
year review of outcomes. Am J Ind Med. 1999;35:232–45.
11. Solomon D, Katz JN, Bahn R, Mogun H, Avorn J. Non-
occupational risk factors for carpal tunnel syndrome. J Gen
Intern Med. 1999;14:310–4.
12. Atcheson S, Ward J, Lowe W. Concurrent medical disease in
work-related carpal tunnel syndrome. Arch Intern Med.
1998;67:541–8.
13. Katz J, Stirrat C, Larson M, Fossel AH, Eaton H. Liang M.A
self-administered hand symptom diagram for the diagnosis
and epidemiologic study of carpal tunnel syndrome. J Rheum.
1990;17:1495–8.
14. Atroshi I, Gummersson C, Johnsson R, Ornstein E, Ranstam J,
Rosen I. Prevalence of carpal tunnel syndrome in a general
population. JAMA. 1999;282:153–8.
15. Andersen J, Thonsem J, Overgaard E, et al. Computer use and
carpal tunnel syndrome: a 1-year follow-up study. JAMA.
2003;289:2963–9.
16. Yassi A, Sprout J, Tate R. Upper limb repetitive strain injuries
in Manitoba. Am J Ind Med. 1996;30:461–72.
17. Hagberg M, Morgenstern H, Kelsh M. Impact of occupa-
tions and job tasks on the prevalence of carpal tunnel syn-
drome. Scand J Work Environ Health. 1992;18:337–45.
18. Hiltz R. Fighting work-related injuries. National Underwriter.
1985;89:15.
19. Concannon M, Brownfield M, Puckett C. The incidence of
recurrence after endoscopic carpal tunnel release. Plast
Reconstr Surg. 2000;105:1662–5.
20. Feuerstein M, Miller V, Burrell L, Berger R. Occupational
upper extremity disorders in the federal workforce: preva-
lence, health care expenditures, and patterns of work
disability. J Occup Environ Med. 1998;40:546–55.
21. Gerritsen AA, de Krom MC, Struijs MA, Scholten RJ, de Vet
HC, Bouter LM. Conservative treatment options for carpal
tunnel syndrome: a systematic review of randomised con-
trolled trials. J Neurol. 2002;249:272–80.
22. O’Connor D, Marshall S, Massy-Westropp N. Non-surgical
treatment (other than steroid injection) for carpal tunnel
syndrome. The Cochrane Library, 2003, Issue 3.
23. Sackett D, Straus S, Richardson S, Rosenberg W, Haynes R.
Evidence-based Medicine: How to Practice and Teach EBM.
2nd ed. New York: Churchill Livingstone, 2000.
April–June 2004 223
24. Manente G, Torrieri F, Di Blasio F, Staniscia T, Romano F,
Uncini A. An innovative hand brace for carpal tunnel syn-
drome: a randomized controlled trial. Muscle Nerve. 2001;
24:1020–5.
25. Walker WC, Metzler M, Cifu DX, Swartz Z. Neutral wrist
splinting in carpal tunnel syndrome: a comparison of night-
only versus full-time wear instructions. Arch Phys Med
Rehabil. 2000;81:424–9.
26. Li S, Liu L, Miyazaki M, Warren S. Effectiveness of splinting
for work-related carpal tunnel syndrome: a three-month
follow-up study. Tech Disabil. 1999;11:51–64.
27. Burke DT, Burke MM, Stewart GW, Cambre A. Splinting for
carpal tunnel syndrome: in search of the optimal angle. Arch
Phys Med Rehabil. 1994;75:1241–4.
28. Daniel E, Paul S. A comparison study of the volar wrist cock-
up splint and ulnar gutter splint in carpal tunnel syndrome.
Occup Ther Health Care. 2000;12:79–93.
29. Ekman-Ordeberg G, Salgeback S, Ordeberg G. Carpal tunnel
syndrome in pregnancy. A prospective study. Acta Obstet
Gynecol Scand. 1987;66:233–5.
30. Courts RB. Splinting for symptoms of carpal tunnel syndrome
during pregnancy. J Hand Ther. 1995;8:31–4.
31. Dolhanty D. Effectiveness of splinting for carpal tunnel
syndrome. Can J Occup Ther. 1986;53:275–80.
32. Ebenbichler GR, Resch KL, Nicolakis P, et al. Ultrasound
treatment for treating the carpal tunnel syndrome: rando-
mised ÔshamÕ controlled trial. BMJ. 1998;316:731–5.
33. Oztas O, Turan B, Bora I, Karakaya MK. Ultrasound therapy
effect in carpal tunnel syndrome. Arch Phys Med Rehabil.
1998;79:1540–4.
34. Tal-Akabi A, Rushton A. An investigation to compare the
effectiveness of carpal bone mobilisation and neurodynamic
mobilisation as methods of treatment for carpal tunnel
syndrome. Man Ther. 2000;5:214–22.
35. Akalin E, El O, Peker O, et al. Treatment of carpal tunnel
syndrome with nerve and tendon gliding exercises. Am J Phys
Med Rehabil. 2002;81:108–13.
36. Carter R, Aspy CB, Mold J. The effectiveness of magnet
therapy for treatment of wrist pain attributed to carpal tunnel
syndrome. J Fam Pract. 2002;51:38–40.
37. Weintraub MI, Cole S. Neuromagnetic treatment of pain in
refractory carpal tunnel syndrome: an electrophysiological
and placebo analysis. J Back Musculoskel Rehab. 2000;15:77–
81.
38. Padua L, Padua R, Moretti C, Nazzaro M, Toral J. Clinical
outcome and neurophysiological results of low-power laser
irradiation in carpal tunnel syndrome. Lasers Med Sci.
1999;14:196–202.
39. Weintraub MI. Noninvasive laser neurolysis in carpal tunnel
syndrome. Muscle Nerve. 1997;20:1029–31.
40. Garfinkel MS, Singhal A, Katz WA, Allan DA, Reshetar R,
Schumacher HRJ. Yoga-based intervention for carpal tunnel
syndrome: a randomized trial. JAMA. 1998;280:1601–3.
41. Manente G, Torrieri F, Pineto F, Uncini A. A relief maneuver in
carpal tunnel syndrome. Muscle Nerve. 1999;22:1587–9.
42. Chen G. The effect of acupuncture treatment on CTS. Am J
Acupunct. 1990;18:5–9.
43. Davis PT, Hulbert JR, Kassak KM, Meyer JJ. Comparative
efficacy of conservative medical and chiropractic treatments
for carpal tunnel syndrome: a randomized clinical trial. J
Manipulative Physiol Ther. 1998;21:317–26.
44. Branco K, Naeser MA. Carpal tunnel syndrome: clinical
outcome after low-level laser acupuncture, microamps trans-
cutaneous electrical nerve stimulation, and other alternative
therapies—an open protocol study. J Altern Complement Med.
1999;5:5–26.
45. Bonebrake AR, Fernandez JE, Marley RJ, Dahalan JB, Kilmer
KJ. A treatment for carpal tunnel syndrome: evaluation of
objective and subjective measures. J Manipulative Physiol
Ther. 1990;13:507–20.
46. Bonebrake AR, Fernandez JE, Dahalan JB, Marley RJ. A
treatment for carpal tunnel syndrome: results of a follow-up
study. J Manipulative Physiol Ther. 1993;16:125–39.
224 JOURNAL OF HAND THERAPY
47. Kruger VL, Kraft GH, Deitz JC, Ameis A, Polissar L. Carpal
tunnel syndrome: objective measures and splint use. Arch
Phys Med Rehabil. 1991;72:517–20.
48. Belanger A. Evidence-based Guide to Therapeutic Physical
Agents. Philadelphia: Williams & Wilkins, 2002.
49. Egger M, Zellweger-Zahner T, Schneider M, Junker C,
Lengeler C, Antes G. Language bias in randomized controlled
trials published in English and German. Lancet. 1997;350:326–
9.
50. Scherer R, Dickersin K, Langenberg P. Full publication of
results initially presented in abstracts. A meta-analysis. JAMA.
1994;272:158–62.
51. Wong E, Lee G, Zucherman J, Mason DT. Successful
management of female office workers with Ôrepetitive stress
injuryÕ or Ôcarpal tunnel syndromeÕ by a new treatment
modality—application of low level laser. Int J Clin Pharmacol
Ther. 1995;33:208–11.
52. Apfel E, Johnson M, Abrams R. Comparison of range-of-
motion constraints provided by prefabricated splints used in
the treatment of carpal tunnel syndrome: a pilot study. J Hand
Ther. 2002;15:226–33.
53. Bahou YG. Carpal tunnel syndrome: a series observed at
Jordan University Hospital (JUH), June 1999–December 2000.
Clin Neurol Neurosurg. 2002;104:49–53.
54. Blankfield RP, Sulzmann C, Fradley LG, Tapolyai AA,
Zyzanski SJ. Therapeutic touch in the treatment of carpal
tunnel syndrome. J Am Board Fam Pract. 2001;14:335–42.
55. Celiker R, Arslan S, Inanici F. Corticosteroid injection vs.
nonsteroidal antiinflammatory drug and splinting in carpal
tunnel syndrome. Am J Phys Med Rehabil. 2002;81:182–6.
56. DeStefano F, Nordstrom DL, Vierkant RA. Long-term symp-
tom outcomes of carpal tunnel syndrome and its treatment.
J Hand Surg [Am]. 1997;22:200–10.
57. Ellis JM, Folkers K, Levy M, et al. Response of vitamin B-6
deficiency and the carpal tunnel syndrome to pyridoxine. Proc
Natl Acad Sci U S A. 1982;79:7494–8.
58. Finestone HM, Woodbury GM, Collavini T, Marchuk Y,
Maryniak O. Severe carpal tunnel syndrome: clinical and
electrodiagnostic outcome of surgical and conservative treat-
ment. Muscle Nerve. 1996;19:237–9.
59. Freedman J. Acupuncture for carpal tunnel syndrome.
Acupunct Med. 2002;20:39–40.
60. Gorsche RG, Wiley JP, Brant R, Renger RF, Sasyniuk TM, Burke
N. Comparison of outcomes of untreated carpal tunnel
syndrome and asymptomatic controls in meat packers. Occup
Med [Lond]. 2002;52:491–6.
61. Harter BTJ, McKiernan JEJ, Kirzinger SS, Archer FW, Peters
CK, Harter KC. Carpal tunnel syndrome: surgical and
nonsurgical treatment. J Hand Surg [Am]. 1993;18:734–9.
62. Kasdan ML, Janes C. Carpal tunnel syndrome and vitamin B6.
Plast Reconstr Surg. 1987;79:456–62.
63. Katz JN, Keller RB, Simmons BP, et al. Maine Carpal Tunnel
Study: outcomes of operative and nonoperative therapy for
carpal tunnel syndrome in a community-based cohort. J Hand
Surg [Am]. 1998;23:697–710.
64. Kimura I, Sekino H, Ayyar DR, Kimura N, Saso S, Makino M.
Carpal tunnel syndrome in patients on long-term hemodial-
ysis. Tohoku J Exp Med. 1986;148:257–66.
65. Koyuncu H, Unber F, Sahin U, Togay P. 1 MHz–3 MHz
ultrasound applications in carpal tunnel syndrome. Fizik
Tedavi Ve Rehabilitasyon Dergisi. 1995;19:141–5.
66. Lederman RJ. Peripheral nerve disorders in instrumentalists.
Ann Neurol. 1989;26:640–6.
67. Luchetti R, Schoenhuber R, Alfarano M, Deluca S, De Cicco G,
Landi A. Serial overnight recordings of intracarpal canal
pressure in carpal tunnel syndrome patients with and without
wrist splinting. J Hand Surg [Br]. 1994;19:35–7.
68. MacDermid J. A hand brace improves symptoms and
function in carpal tunnel syndrome. Aust J Physiother. 2002;
48:134.
69. Mariano KA, McDougle MA, Tanksley GW. Double crush
syndrome: chiropractic care of an entrapment neuropathy. J
Manipulative Physiol Ther. 1991;14:262–5.
70. Miller RS, Iverson DC, Fried RA, Green LA, Nutting PA.
Carpal tunnel syndrome in primary care: a report from ASPN.
Ambulatory Sentinel Practice Network. J Fam Pract.
1994;38:337–44.
71. Naeser MA. Acupuncture and laser acupuncture in the
treatment of paralysis in stroke patients, carpal tunnel
syndrome and alopecia areata. Frontier Perspectives.
1996;5:8–15.
72. Naeser MA, Hahn KA, Lieberman BE, Branco KF. Carpal
tunnel syndrome pain treated with low-level laser and
microamperes transcutaneous electric nerve stimulation:
a controlled study. Arch Phys Med Rehabil. 2002;83:978–88.
73. Nathan PA, Wilcox A, Emerick PS, Meadows KD, McCormack
AL. Effects of an aerobic exercise program on median nerve
conduction and symptoms associated with carpal tunnel
syndrome. J Occup Environ Med. 2001;43:840–3.
74. Petruska G. Carpal tunnel syndrome: a new perspective that
blends active and passive care. J Sports Chiropract Rehab.
1997;11:57–60, 83–4.
75. Rempel D, Tittiranonda P, Burastero S, Hudes M, So Y. Effect of
keyboard keyswitch design on hand pain. J Occup Environ
Med. 1999;41:111–9.
76. Schiottz B, Mooney V, Azad S, Selstad D, Gulick J, Bracker M.
The role of active release manual therapy for upper extremity
overuse syndromes—a preliminary report. J Occup Rehab.
1999;9:201–11.
77. Seradge H, Parker W, Baer C, Mayfield K, Schall L. Conserva-
tive treatment of carpal tunnel syndrome: an outcome study of
adjunct exercises. J Okla State Med Assoc.. 2002;95:7–14.
78. Silverstein L. Biofeedback training (BFT) for carpal tunnel
syndrome: a case report with a five-year follow-up. Am J Clin
Biofeedback. 1983;6:111–7.
79. Smith R. Is microcurrent stimulation effective in pain
management? An additional perspective. Am J Pain Manage.
2001;11:64–8.
80. Stolp-Smith KA, Pascoe MK, Ogburn PLJ. Carpal tunnel
syndrome in pregnancy: frequency, severity, and prognosis.
Arch Phys Med Rehabil. 1998;79:1285–7.
APPENDIX 1
Literature Search Terms
Condition terms
Carpal tunnel syndrome
Carpal tunnel
Median nerve compression
Intervention terms
Physical therapy
Physiotherapy
Rehabilitation
Exercise
Ultrasound
Laser OR lasers
Brace OR bracing
Orthosis OR orthoses
Splint OR splints OR splinting
Range of motion
Manipulation
Mobilization OR mobilization
Joint mobilization OR joint mobilization
Occupational therapy
Iontophoresis
Glide OR gliding
Transcutaneous electric nerve stimulation
81. Stransky M, Rubin A, Lava NS, Lazaro RP. Treatment of carpal
tunnel syndrome with vitamin B6: a double-blind study. South
Med J. 1989;82:841–2.
82. Sucher BM. Myofascial manipulative release of carpal tunnel
syndrome: documentation with magnetic resonance imaging.
J Am Osteopath Assoc. 1993;93:1273–8.
83. Sucher BM. Myofascial release of carpal tunnel syndrome.
J Am Osteopath Assoc. 1993;93:92–4.
84. Sucher BM. Palpatory diagnosis and manipulative manage-
ment of carpal tunnel syndrome. J Am Osteopath Assoc.
1994;94:647–63.
85. Talkington S. Neuromuscular disorders. Rehab Management
Interdisc J Rehab. 1997;10:76–7.
86. Thomas R, Vaidya S, Herick R, Congleton J. Effects of exercise
on carpal tunnel syndrome symptoms. Appl Ergon. 1993;
24:101–8.
87. Tittiranonda P, Rempel D, Armstrong T, Burastero S. Effect of
four computer keyboards in computer users with upper
extremity musculoskeletal disorders. Am J Ind Med. 1999;
35:647–61.
88. Trimm A, Evans JH. Carpal tunnel syndrome. A note on
conservative treatment. Practitioner. 1966;196:410–2.
89. Valente R, Gibson H. Chiropractic manipulation in carpal
tunnel syndrome. J Manipulative Physiol Ther. 1994;17:246–9.
90. van Rossum J, Kamphuisen HA, Wintzen AR. Management in
the carpal tunnel syndrome: clinical and electromyographical
follow-up in 62 patients. Clin Neurol Neurosurg. 1980;82:169–76.
91. Waring WP, Werner RA. Clinical management of carpal tunnel
syndrome in patients with long-term sequelae of poliomyeli-
tis. J Hand Surg [Am]. 1989;14:865–9.
92. Wolaniuk A, Vadhanavikit S, Folkers K. Electromyographic
data differentiate patients with the carpal tunnel syndrome
when double blindly treated with pyridoxine and placebo.
Res Commun Chem Pathol Pharmacol. 1983;41:501–11.
93. Yoshida T, Daikoku H, Yamamoto H, Saitoh S. Saitoh H.A
flexible dorsal wrist splint. J Hand Ther. 1993;6:323–5.
94. Carpal tunnel syndrome in pregnancy: a prospective clinical
study. J Maternal Fetal Invest. 1994;4:47–9.
April–June 2004 225
 Neuromuscular stimulation
Electric stimulation
Conservative measure OR conservative measures
Conservative therapy OR conservative therapies
Conservative management
Conservative treatment OR conservative treatments
Kinesiotherapy

APPENDIX 2
Structured Effectiveness Quality Evaluation Scale (SEQES)
Evaluation Criteria Score

Study question 2 1 0
1. Was the relevant background work cited to establish a foundation for the research question?
Study design
2. Was a comparison group used?
3. Was patient status at more than one time point considered?
4. Was data collection performed prospectively?
5. Were patients randomized to groups?
6. Were patients blinded to the extent possible?
7. Were treatment providers blinded to the extent possible?
8. Was an independent evaluator used to administer outcome measures?
Subjects
9. Did sampling procedures minimize sample/selection biases?
10. Were inclusion/exclusion criteria defined?
11. Was an appropriate enrollment contained?
12. Was appropriate retention/follow-up obtained?
Intervention
13. Was the intervention applied according to established principles?
14. Were biases due to the treatment provider minimized (ie attention, training)?
15. Was the intervention compared to appropriate comparator?
Outcomes
16. Was an appropriate primary outcome defined?
17. Were appropriate secondary outcomes considered?
18. Was an appropriate follow-up period incorporated?
Analysis
19. Was an appropriate statistical test(s) performed to indicate differences related to the intervention?
20. Was it established that the study had significant power to identify treatment effects?
21. Was the size and significance of the effects reported?
22. Were missing data accounted for and considered in analyses?
23. Were clinical and practical significance considered in interpreting results?
Recommendations
24. Were the conclusions/clinical recommendations supported by the study objectives, analysis, and results?
Total quality score (sum of above)=
Level of Evidence (Sackett) 1 2 3 4 5
Ó Joy MacDermid, 2003.

APPENDIX 3
Abbreviation List for Results Tables

Table Headings Abbreviations:

LOE: Level of Evidence
QS: Quality Score (SEQES)
Subjects Abbreviations:
C: Control group
Rx: Treatment group
Sx: Surgery
Yrs: Years
Intervention Abbreviations:
Ext: Extension
HVLAT: High-Velocity, Low-Amplitude Thrusts

226 JOURNAL OF HAND THERAPY

MOs: Months
Reps: Repetitions
Sec: Seconds
US: Ultrasound
Wks: Weeks
Evaluation Abbreviations:
AROM: Active Range of Motion
BCTQ: Boston Carpal Tunnel Questionnaire
CTOA—M: Carpal Tunnel Outcome Assessment—Mental Distress
CTOA—P: Carpal Tunnel Outcome Assessment—Physical Distress
DSL/SDL: Distal Sensory Latency/Sensory Distal Latency
DML/MDL: Distal Motor Latency/Motor Distal Latency
EMG: Electromyography
FSS: Functional Status Scale
HAND: Hand–Finger Functioning Scale
PAD: Pain and Distress
PRS: Pain Relief Scale
ROM: Range of Motion
SCV: Sensory Conduction Velocity
SNAP: Sensory Nerve Action Potential
SGICQ: Subjects’ Global Impression of Change Questionnaire
SSS: Symptom Severity Scale
ULTT: Upper Limb Tension Test
Results Abbreviations:
See above sections

Excluded Article
52
Apfel et al., 2002
Bahou, 200253
Blankfield et al., 200154
Celiker et al., 200255
DeStefano et al., 199756
Ellis et al., 198257
Finestone et al., 199658
Freedman, 200259
Gorsche et al., 200260
Harter et al., 199361
Kasdan and Janes, 198762
Katz et al., 199863
Kimura et al., 198664
Koyuncu et al., 199565
Kruger et al., 199147
Lederman, 198966
Luchetti et al., 199467
MacDermid, 200268
Mariano et al., 199169
Miller et al., 199470
Naeser, 199671
Naeser, 200272
Nathan et al., 200173
Petruska, 199774
Rempel, 199975
Schiottz-Christensen et al., 199976
Seradge et al., 200277
Silverstein 198378
Smith, 200179
Stolp-Smith et al., 199880
APPENDIX 4
Excluded Studies
Reason for Exclusion
Not study of treatment effects
Not study of treatment effects
Subjects with previous surgery
Not only physiotherapy (PT), occupational therapy (OT), or hand therapy treatment
Not only PT, OT, or hand therapy treatment
Not within PT, OT, or hand therapy scope of practice
Not only PT, OT, or hand therapy treatment
Case report
Not study of treatment effects
Not only PT, OT, or hand therapy treatment
Not only PT, OT, or hand therapy treatment
Not only PT, OT, or hand therapy treatment
Not study of treatment effects
Not English (Turkish)
Traumatic CTS
Not study of treatment effects
Not study of treatment effects
Treatment protocol not feasible for physiotherapy practice
Not a study (commentary)
Case report
Not study of treatment effects
Not a study (description/report of study protocol)
Subjects had surgery
Not study of treatment effects (28 prevention)
Case report
Not only PT, OT, or hand therapy treatment
Subjects with other pathologies (not only CTS)
Not only PT, OT, or hand therapy treatment
Case report
Subjects with other pathologies (not only CTS)
Not study of treatment effects

April–June 2004 227

Stransky et al., 198981 Not only PT, OT, or hand therapy treatment
Sucher, 1993A82 Case report
Sucher, 1993B83 Case report
Sucher, 199484 Case report
Talkington, 199785 Not a study (narrative review)
Thomas et al., 199386 Subjects not diagnosed with CTS
Tittiranonda, 199987 Not only PT, OT, or hand therapy treatment
Trimm and Evans, 196688 Not only PT, OT, or hand therapy treatment
Valente and Gibson, 199489 Case report
Van Rossum et al., 198090 Not only PT, OT, or hand therapy treatment
Waring and Werner, 198991 Subjects with previous surgery
Wolaniuk et al., 198392 Not within PT, OT, or hand therapy scope of practice
Yoshida et al., 199393 Not study of treatment effects
Yorulmaz et al., 199494 Not study of treatment effects
CTS = carpal tunnel syndrome.

APPENDIX 5
Sackett’s Levels of Evidence, Grades of Recommendations
Level of Evidence and Definitions

Level of Evidence General Criteria for Level of Evidence

1a Systematic review of homogeneous of randomized, controlled trials (RCTs)

1b Single high-quality RCT
1c All or none study
2a Systematic review of homogeneous cohort studies
2b Single cohort study (including low-quality RCT; ie less than 80% follow up)
2c ‘‘Outcomes’’ research; ecological studies
3a Systematic review of homogeneous case–control studies
3b Single case–control study
4 Case-series, low-quality cohort and case–control studies
5 Expert opinion without explicit critical appraisal, or based on physiology or ‘‘first principles’’

Grades of Recommendations and Definitions

Grade of Recommendation General Criteria for Grade of Recommendation

A Consistent level 1 studies

B Consistent level 2 or 3 studies (or extrapolations from level 1 studies)
C Level 4 studies (or extrapolations from level 2 or 3 studies)
D Level 5 evidence (or inconsistent or inconclusive studies of any level)

Relation of Grades of Recommendation to Levels of evidence

Grade of Recommendation Level of Evidence

A 1a
1b
1c
B 2a
2b
2c
3a
3b
C 4
D 5
Adapted with permission from: Sackett D, Straus S, Richardson S, Rosenberg W, Haynes R. Evidence-based Medicine: How to Practice and
Teach EBM, 2nd ed. New York: Churchill Livingstone, 2000 and web site: http://www.cebm.net/levels_of_evidence.asp#notes. Accessed
December 1, 2004.

228 JOURNAL OF HAND THERAPY