Effectiveness of non-operative methods of treatment of carpal tunnel syndrome: a narrative review

Abstract

Introduction. Carpal tunnel syndrome (CTS) can be treated with several methods, including surgical and non-surgical techniques. Non-surgical methods include wrist splinting, systemic pharmacotherapy, intracarpal injections of steroids hydrodissection, acupuncture, nerve and tendon mobilization, osteopathy, taping, topical application of ointments, laser, ultrasound and shock-wave therapies. These treatments are generally less effective than surgery, and provide only short-lived effect, but it may be quite sufficient for a certain category of patients, particularly those suffering from mild symptoms. Over the last years, these techniques have attracted increasing popularity, because they offer non-invasive option for surgical treatment what can be attractive for some patients. However, although these methods were shown in the literature, their actual effectiveness has not been scientifically verified. The objective of this study was a review of the effectiveness of non-operative methods of treatment of CTS. Methods. A review of the published literature from PubMed and Medline databases on the effectiveness of CTS non-operative treatments of was done. Results. The review indicates that each of the presented methods is effective in reduction of symptoms and improvement of hand function in CTS patients, but their effect is only short-lived. None of these treatments provides a permanent cure, like does surgical treatment. Conclusion. In spite of numerous non-operative treatments of CTS, surgery is the only method that provides permanent recovery.

Full text

2536
© Aluna Publishing
Wiadomości Lekarskie Medical Advances, VOLUME LXXVII, ISSUE 12, DECEMBER 2024
INTRODUCTION
Carpal tunnel syndrome (CTS) is caused by compression
of the median nerve in the carpal tunnel. It is the most
common compression neuropathy, aecting 1-1.5% of
the total population and about 6% of women over 40
years of age. Middle-aged and elderly women are the
largest group aected by this condition. The age of
onset varies: in the clinic managed by the author, the av-
erage age of women admitted for carpal tunnel release
was 57 years. Although several predisposing factors are
known (diabetes, hypothyroidism, rheumatoid arthri-
tis), in about 80% of cases the cause of the syndrome
cannot be determined (an idiopathic syndrome) [1-8].
Carpal tunnel syndrome can be treated with several
methods [1, 2, 6, 7]. Although surgical treatment (cut-
ting of exor retinaculum) is most often used, other,
non-surgical methods have their place in the CTS
management. These include immobilization of the
wrist joint in a splint or orthosis, various methods of
physiotherapy, systemic pharmacotherapy and local in-
jections of steroids. Conservative treatment is generally
considered to be less eective than surgery and only
temporary eective, but it may be quite sucient for a
certain category of patients, particularly those suering
from mild symptoms. Over the last years, non-operative
methods of treating carpal tunnel syndrome have to be
oered, such as: hydrodissection, acupuncture, nerve
and tendon mobilization, osteopathy, taping, topical
application of ointments, as well as laser, ultrasound and
shock-wave therapies. These techniques have attracted
increasing popularity, because they oer non-invasive
option for surgical treatment what can be attractive
for some patients. However, although these methods
were shown in the literature, their actual eectiveness
has not been scientically veried.
AIM
The objective of this study was to review an eective-
ness of non-operative methods of the treatment of
carpal tunnel syndrome.
MATERIAL AND METHODS
This article presents a review of the published literature
from PubMed and Medline databases on the eec-
Eectiveness of non-operative methods of treatment of carpal
tunnel syndrome: a narrative review
Andrzej Żyluk1, Alicja Żyluk2
1DEPATRMENT OF GENERAL AND HAND SURGERY, POMERANIAN MEDICAL UNIVERSITY, SZCZECIN, POLAND
2
DEPARTAMENT OF GENERAL NAD HAND SURGERY, STUDENT’S SCIENTIFIC CIRCLE, POMERANIAN MEDICAL UNIVERSITY, SZCZECIN, POLAND
ABSTRACT
Carpal tunnel syndrome (CTS) can be treated with several methods, including surgical and non-surgical techniques. Non-surgical methods include wrist splint-
ing, systemic pharmacotherapy, intracarpal injections of steroids hydrodissection, acupuncture, nerve and tendon mobilization, osteopathy, taping, topical
application of ointments, laser, ultrasound and shock-wave therapies. These treatments are generally less eective than surgery, and provide only short-lived
eect, but it may be quite sucient for a certain category of patients, particularly those suering from mild symptoms. Over the last years, these techniques
have attracted increasing popularity, because they oer non-invasive option for surgical treatment what can be attractive for some patients. However, although
these methods were shown in the literature, their actual eectiveness has not been scientically veried. The objective of this study was a review of the
eectiveness of non-operative methods of treatment of CTS. A review of the published literature from PubMed and Medline databases on the eectiveness of
CTS non-operative treatments of was done. The review indicates that each of the presented methods is eective in reduction of symptoms and improvement
of hand function in CTS patients, but their eect is only short-lived. None of these treatments provides a permanent cure, like does surgical treatment. In spite
of numerous non-operative treatments of CTS, surgery is the only method that provides permanent recovery.
KEY WORDS: carpal tunnel syndrome, non-operative treatment, outcomes of the treatment, literature review
Wiad Lek. 2024;77(12):2536-2545. doi: 10.36740/WLek/196561 DOI
REVIEW ARTICLE CONTENTS

Eectiveness of non-operative methods of treatment of carpal tunnel syndrome: a narrative review
2537
tiveness of non-operative treatments of carpal tunnel
syndrome. A randomized clinical trials, systematic
reviews and meta-analyses reporting on use of these
methods were reviewed. Keywords used at searching
articles were: carpal tunnel syndrome, non-operative
treatment, clinical outcomes, treatment eectiveness,
systematic review, meta-analysis and treatment com-
plications.
REVIEW AND DISCUSSION
The results of the literature review will be presented
separately for each non-standard treatment. First three
paragraphs will end with the author’s comment on the
results presented.
HYDRODISSECTION
USG-guided injection (also named as hydrodissection
or perineural injection) delivering a range of injec-
tates, i.e. normal saline, corticosteroids, dextrose and
platelet-rich plasma attracts growing popularity in the
treatment of CTS [9-13]. In assumption, this procedure,
provides a mechanical eect to release and decompress
the entrapped nerves and adds a pharmacological
eect of delivered drug relieving pain and promoting
recovery. During hydrodissection, ultrasound guidance
is used to identify the nerve and guide the needle to the
nerve. After this, an adequate volume of an injectate is
placed around the nerve to separate it from surround-
ing tissue, fascia, or adjacent structures that may be
compressing the nerve. The volume of uid injected
into carpal tunnel varies from 4 to 10 ml.Depending
on the patient, only one treatment may be needed,
but this procedure typically needs to be repeated 2-3
times to achieve the expected result.
Several publications presenting eectiveness of this
procedure using various injectates were published [9-
13]. Most studies compared dierent ultrasound-guid-
ed interventions to dierent comparison injectate or
other conservative treatments such as wrist splinting
or physical therapy, but none compared a matched
intervention and comparison groups. Various injectates
were used such as 0,9% saline solution, 5% dextrose
solution, corticosteroids, local anaesthetics, hyaluronic
acid, platelet-rich plasma and ozone. Outcome mea-
sures after intervention included pain intensity in the
Numeric Rank Scale (NRS, range 0-10, higher means
stronger pain), Boston Carpal Tunnel Questionnaire
(BCTQ; range 1-5, higher means worse symptoms and
greater disability) and Disability of Arm, Shoulder and
Hand questionnaire (DASH; range 0-100, higher means
greater disability) as well as the electrodiagnostic stud-
ies. Results reported in these studies show generally
good results after hydrodissection procedure using
various injectates, in terms of cessation of pain, clinical
improvement (decreasing of BCTQ and DASH scores)
and improvement of electrodiagnostic parameters.
All considered variables were statistically signicantly
better after treatment, comparing to baseline [10, 11].
Yang et al. reported results of investigations of ef-
cacy of various injectates used in hydrodissection
procedures in the treatment of carpal tunnel syndrome
through a network meta-analysis of randomized control
trials. Platelet-rich plasma was identied to be the most
eective injectant for short-term functional improve-
ment and pain relief. Platelet-rich plasma is the pro-
cessed liquid fraction of autologous peripheral blood
with a platelet concentration. The authors conclude
that results of their network meta-analysis show that
platelet-rich plasma can be used as rst-line treatment
for carpal tunnel syndrome, and other injectates such
as 5% dextrose and steroids may serve as alternative
treatments [13].
Interestingly, favourable outcomes after hydrodissec-
tion procedure were observed also in a control groups
using injections with plain saline or local anaesthetics;
unfortunately there were no clear placebo-controlled
trials. However considering normal saline injection as
placebo, these results may suggest that hydrodissection
itself results in clinical improvement, regardless the
injectate used [9, 11, 12]. No serious adverse events
were reported after hydrodissection. Results of the
analysis of literature on use of this procedure show that
USG-guided hydrodissection is a safe but only tempo-
rary eective treatment for mild to moderate CTS. A
major rationale for using this technique is to reduce the
risk of iatrogenic nerve injury during blind intracarpal
injection of various substances.
CRITICAL COMMENT
Current evidence supporting use of hydrodissection for
carpal tunnel syndrome has a signicant drawback: a
short follow-up. Almost all studies presented results up
to 6 months! There may be concern that after a longer
time the symptoms may return in most patients. In
essence, hydrodissection does not dier much from
ordinary steroid or hyaluronic acid injections. Although
it is ultrasound-guided and more uid is injected into
the carpal tunnel, but the procedure does not change
anatomical relations in the carpal tunnel. The only
procedure that changes the anatomical relations in the
carpal tunnel is surgical cutting the exor retinaculum.
When all structures in the carpal tunnel remain unchan-
ged, it is dicult to assume that the pressure on the me-

Andrzej Żyluk, Alicja Żyluk
2538
dian nerve, which was reduced after the intervention,
will not return after a shorter or longer period of time.
Therefore benecial eect of hydrodissection repor-
ted in many studies should be treated with caution as
potentially short-lived. The reviewed literature also did
not provide any evidence that patients with CTS who
underwent hydrodissection will avoid surgery in the
future.Therefore the assurances of some doctors that
hydrodissection is as eective treatment as surgery and
without unpleasant adverse eects are unfair.
STEROID INJECTION
Intracarpal steroid injection is one of the most common-
ly accepted treatment among the various conservative
managements for CTS. There are several supposed
mechanisms of action of local steroids in carpal tunnel
syndrome, including:
• Anti- inammatory eect by inhibiting the produc-
tion of inammatory cytokines by lymphocytes and
macrophages in the tenosynovium.
• Antibrotic eect via the suppression of collagen
expression.
• Anti-oedematous eects through reduced vascular
permeability.
Activation of all these mechanisms results in a bene-
cial eect in the form of cessation of symptoms and
improvement of hand function [13-17]. In some studies
an improvement in electrophysiological parameters in
the median nerve has also been observed [15, 17]. Basi-
cally 3 substances are used for injections: triamcinolone,
methylprednisolone and betamethasone. Eectiveness
all these injectates is similar and their use depends
mainly on the individual surgeon’s preference. Steroids
are injected into carpal tunnel with landmark-guided
technique or with USG guidance; the former technique
is much more common, but it carries some risk of in-
traneural injection, even with correct needle insertion
and localization. Therefore, ultrasound-guided injection
is gradually applied for accurate localization of intracar-
pal structures. However, landmark-guided injection still
seems to be one of the most available management
procedures, attributed to good eectiveness, more
convenience, and lower cost [17].
In general 1-3 injections at 2-4 week intervals are
needed to achieve permanent improvement, but some
patients respond excellently to one injection. Steroid
injections provide a very quick relief of symptoms,
usually within 24 hours after the injection, which is
why patients often ask for such treatment. This applies
especially to patients with severe symptoms who are
referred for surgical treatment, but their waiting time
is long, i.e. several weeks or months.
There is abundant literature on steroid injections for
carpal tunnel syndrome. We provide reviews of only
several studies.
Marshall et al., presented results of systematic review
of on the ecacy of local steroid injections in carpal tun-
nel syndrome [14]. They included 12 studies involving
altogether 671 participants. Results of this analysis show
Fig. 1. Application of shock wave in
carpal tunnel syndrome.

Eectiveness of non-operative methods of treatment of carpal tunnel syndrome: a narrative review
2539
are very satisfied with such therapy. It is safe and
cheap, unlike other, non-operative treatments, which
are usually much more expensive and similarly (or
less) eective. The method is safe, both when given
with landmark-guided method or with USG guidance.
Steroid injection also has diagnostic value: in doubtful
cases, signicant improvement after steroid injection
conrms diagnosis of carpal tunnel syndrome and that
surgical treatment should be eective.
SPLINTING
Among the non-operative treatment modalities
splinting has emerged as a rst-line treatment in mild
to moderate CTS [18-23]. Splints are typically recom-
mended for use at night, but may also be worn during
daytime hours depending on patient work and activity
demands. By maintaining the wrist in a neutral posi-
tion, splints prevent the extremes of wrist exion and
extension, which have been shown to increase pressure
within the carpal tunnel, irritate the median nerve and
causes symptoms. Most of splints only immobilize the
wrist, but some extend distally and keep the metacar-
pophalangeal joints extended. This (theoretically) pre-
vents the lumbrical muscles from proximal migration
and entering the carpal tunnel. There are many studies
in the literature supporting the use of splints in mild to
moderate CTS. Older studies reported signicant bene-
cial eect of splinting. Manente et al. (2001) reported
signicant reduction of nocturnal symptoms (pain and
numbness) and functional improvement, after use of a
soft hand splint at night for 4 weeks, when compared
with a control group [18]. Other studies reported similar
benets from splinting [19-22].
However, an updated meta-analysis of the literature
by Karjalainen et al. showed dierent picture. Results
of recent studies showed that night splinting provides
little or no benets in reduction of symptoms in the
short term (< 3 months) and does not improve hand
function in the short and long term (> 6 months). In
the short and long term, the mean BCTQ was 0,24
points better after splinting compared with no active
treatment. The Minimal Clinically Important Dierence
(MCID) for BCTQ is 0,7 points, what means that this im-
provement was not clinically meaningful. Nevertheless,
these variables were better after splinting compared to
before treatment [23].
An assessment of ecacy of splinting as an additional
treatment to steroid injection, rehabilitation, kinesiol-
ogy taping, rigid taping or extracorporeal shock wave
treatment (ESWT) showed that splinting does not pro-
vide additional benets in reduction of symptoms or
improvement of hand function when given together
that in most studies steroid injection provides greater
symptom relief one month after injection, compared to
placebo, however this eect was short-living and was
not demonstrated beyond one month. Other ndings
from this study are as follows: steroid injection provides
signicantly greater clinical improvement than oral
corticosteroid for up to three months; steroid injec-
tion does not signicantly improve clinical outcome
compared to either anti-inammatory treatment and
splinting after two months or laser treatment after
6 months; two local corticosteroid injections do not
provide signicant added clinical benet compared to
one injection [14].
In a more recent study, Ashworth et al. presented
results of Cochrane database systematic review of pla-
cebo-controlled studies investigating the ecacy of
local steroid injections for CTS [15]. The authors found
14 trials with 994 participants. The main conclusion
from this analysis is that intracarpal steroid injections
are eective for the treatment of mild and moderate
CTS with benets lasting up to six months. Another
nding is that this therapy reduces need for surgical
treatment of the syndrome up to 12 months. All studies
reported a very low risk of serious adverse events [15].
Similar conclusions were presented in study by Yang
et al., (2024), who presented results of a systematic
review and network meta-analysis of randomized con-
trolled trials on the eectiveness of injection therapy
using various injectables for CTS. In the part relating
to the use of steroids these authors state that steroid
injections are eective in terms of symptom and pain
relief as well as functional improvement in the short
term (up to 6 months) but not in the long term [13].
Kaile et al., reported results of the study investigating
safety of landmark-guided steroid injections with 40 mg
triamcinolone for CTS. These authors have encountered
only 4 serious complications in 9515 injections. At
routine follow-up, 6 weeks after injection 33% patients
reported some side eects, the most commonly it was
short-lived local pain (13%) which resolved in all cases
within 3 weeks. No cases of intraneural injection or
tendon rupture occurred. Most adverse eects were
transient, only 13 hands exhibited persistent skin de-
pigmentation or subcutaneous atrophy. The authors
conclude that landmark-guided intracarpal steroid
injection is safe procedure, burdened with a very low
risk of complications [16].
CRITICAL COMMENT
Intracarpal steroid injections are commonly used in
the treatment of CTS. Although it is well known that
it does not provide a permanent cure, many patients

Andrzej Żyluk, Alicja Żyluk
2540
disorders in which the laser is used. The most common
treatment protocol involved 5 laser sessions a week for
a total of 2-3 weeks. Three or 5 application points over
the course of the median nerve at the wrist was the
most commonly used action position. Dierent laser
irradiation energy doses were used, from 2,7 to 11 J
(Joule) for each point or as total energy from 81 to 300
J for the entire treatment [24, 26].
Results of older studies showed reduction of pain and
improvement of hand function in patients who received
2-3 weeks laser therapy, however all these studies were
uncontrolled [24, 25]. Li et al., (2016) reported results of
a meta-analysis of placebo-controlled studies published
in recent years. Results of these studies have shown
a short-term (3 months in average) benecial eects
of laser therapy on clinical and electrophysiological
parameters in the CTS. These ndings, however, were
not consistent because of dierent laser intervention
protocols used in these studies. Moreover, the func-
tional mechanism of low-level lasers is not clear, and
some studies suggested that laser irradiation did not
change the functional properties of peripheral nerves
[26]. The fundamental disadvantage of these studies
is very short follow-up period. Therefore benecial
eect of laser therapy reported in these studies should
be treated with caution as potentially short-lived. The
reviewed literature also did not provide any evidence
that patients with CTS who underwent laser therapy
will avoid surgery in the future.
ULTRASOUND THERAPY
Ultrasound (US) treatment within an intensity range
of 0,5 – 2,0 W/cm2 may have the potential to induce
various biophysical eects within tissue. The rationale
of using US therapy in carpal tunnel syndrome is based
on results of some studies which showed its benecial
eects such as an anti-inammatory eect, stimulation
of nerve regeneration via enhanced blood ow, and
membrane permeability, as well as improvement of
conduction properties in the nerve. Activation of these
mechanisms by US treatment might (in assumption)
facilitate recovery from nerve compression [27, 28].
Results of study by Ebenbichler et al., (1998) showed
that pulsed ultrasound at frequency of 1MHz, and
energy of 1,0 W/cm2 applied to the palmar side of the
wrist over 15 min for ten consecutive days, followed
by twice weekly treatments for ve additional weeks
resulted in cessation of pain and nocturnal paresthesiae,
improved sensation in the ngers innervated by the
median nerve, increased grip and pinch strength and
improved electrophysiological parameters. Treatment
eects were observed up to 6 months [27]. However,
with these measures. Results of some studies showed
that splinting for 12 weeks was not better than 6 weeks,
but 6 months of splinting was more benecial than 6
weeks of splinting in cessation of symptoms and im-
proving of hand function [23].
The evidence whether splinting benets patients with
carpal tunnel syndrome is not clearly convincing. This
means possibility of small improvements in symptoms
and hand function, but they may not be clinically mean-
ingful. Results of some studies suggest that patients
may experience overall improvement with night-time
splints comparing to no treatment. As splinting is sim-
ple, cheap and safe, even small eects could justify its
use, particularly when patients are afraid of more inva-
sive treatments. It is unclear if a splint is optimally worn
full time or at night-time only and whether long-term
use is better than short-term use, but some evidence
suggests that the benets may manifest in the long
term [19, 22].
CRITICAL COMMENT
Splinting is now considered an eective treatment for
mild CTS, devoid of adverse eects, although somewhat
inconvenient for patients. However, it should be stated
that it is a good method only for patients with mild
symptoms who do not feel discomfort during the day
and without impaired hand function. Such a clinical
presentation concerns only about 5% of patients, which
is a signicant minority. The author’s experience shows
that night splinting never results in full recovery and
almost all patients treated with this method are eventu-
ally operated on. Night splinting is also recommended
for the waiting time for surgery, which can take up to
several months. This allows patients survive the waiting
time in greater comfort. An intracarpal steroid injection
is similarly eective procedure used in patients who are
waiting for surgery and suer from severe pain.
OHER NONINVASIVE TREATMENTS.
Other, less commonly used non-invasive treatments will
be presented in short paragraphs, below.
LOW-LEVEL LASER THERAPY
The benecial eect of the low-level laser in CTS is (in
theory) achieved through several mechanisms, such
as increasing myelin production, anti-inammatory
eects, selective inhibition of nociceptive activation
at peripheral nerves, increased ATP production and
improvement of blood circulation in the median nerve
[24-26]. These mechanisms are also mentioned in other

Eectiveness of non-operative methods of treatment of carpal tunnel syndrome: a narrative review
2541
no additional placebo-controlled studies were available
to support the actual eect of US, with certain studies
calling its utility into question [21, 28]. Finally, Page
et al., (2013) presented results of Cochrane review of
studies presenting results of treatment of carpal tunnel
syndrome with ultrasound therapy and concluded that
there is only poor quality evidence from very limited
data to suggest that therapeutic ultrasound may be
more eective than placebo for either short- or long-
term symptom improvement in CTS patients. They also
stated that is insucient evidence to support the use
of therapeutic ultrasound as a treatment with greater
ecacy compared to other conservative treatments,
such as splinting, physiotherapy, steroid injections and
oral drugs [28].
ACUPUNCTURE
Acupuncture aims to stimulate trigger points along the
meridian, a proposed pathway of energy through the
body. Meridian is a concept from traditional Chinese
medicine. According to this concept, meridians form a
system of channels wrapping around the human body.
They connect to the organs of the body that play a key
role in the production, processing, and transmission of
energy called Qi. Optimizing this energy pathway is be-
lieved to have benecial eect in CTS without altering
mechanical pressures within the carpal tunnel [21]. The
mechanism of action of acupuncture remains unknown,
proposed theories include a neuromodulatory eect
on pain perception by promoting endogenous central
nervous system analgesic production and activating
anti-inammatory pathways [21, 29, 30].
In a recent Cochrane review compiling 12 studies and
869 patients, Choi et al. concluded that acupuncture
may have little or no short-term eect on CTS symp-
toms in comparison with placebo or sham procedures
[31]. This was largely attributed to heterogeneity of the
studies and the risk of bias. The authors also stated that
the adverse eects of acupuncture, such as skin bruising
and local pain after needle insertion, are inconsistently
reported among trials and must be documented to
comprehensively assess risks and benets prior to rec-
ommending treatment [31].
EXTRACORPOREAL SHOCK WAVE THERAPY
Extracorporeal shock wave therapy (ESWT) has been
used for the treatment of CTS as a novel and non-inva-
sive method (Fig. 1) [32-35]. The mechanism of action of
ESWT in carpal tunnel syndrome is not fully understood;
the proposed theories include the anti-inammatory
and neuronal regeneration eects as potential mode
of action. The anti-inammatory eect is similar to ob-
served in other musculoskeletal disorders treated with
ESWT. This eect on intracarpal structures can modulate
the perineural pressure and promote cessation of CTS
symptoms. Second proposed mechanism is induction
of peripheral nerve regeneration by accelerating the
elimination of the injured axon, increasing Schwann cell
proliferation, and increasing axonal regeneration. These
mechanisms can have eect on improvement of clinical
symptoms and electrophysiologic parameters [32, 33].
Xu et al., reported results of randomised study com-
paring the eect of ESWT vs steroid injection in mild
and moderate carpal tunnel syndrome. At the 3 months
follow-up, a statistically signicantly greater eect on
reduction of symptoms and improvement of function
was noted for the ESWT group than for the steroid injec-
tion group. For the nerve conduction study, there was a
signicant improvement in the median nerve sensory
nerve action potential distal latency at the 3 months
follow-ups for the ESWT group. The authors conclude
that ESWT is a useful non-invasive short-term treatment
for mild to moderate carpal tunnel syndrome and elicits
a better recovery than local steroid injection [33].
Kim et al., presented results of a systematic review
and meta-analysis of randomized controlled trials on
the eect of ESWT in carpal tunnel syndrome. These
authors found 6 studies meeting the requirements
for analysis, involving a total of 261 patients. Based on
results of this analysis they noted that ESWT treatment
improves symptoms, functional outcomes, and electro-
physiologic parameters in patients with CTS, however,
there was no obvious dierence between the ecacies
of ESWT and local corticosteroid injection. No serious
side eects were reported in all included studies [34].
In contrast, results of recent meta-analysis by Chen
et al., (2022) which involved 7 randomized controlled
trials with a total of 376 participants showed that at
the 3 months follow-up, the ESWT did not demonstrate
superior ecacy compared to treatment with night
wrist splinting alone. The authors conclude that the
therapeutic eect of ESWT is transient and mostly
nonsignicant [35].
SHORTVAWE AND ELECTROMAGNETIC
DIATHERMY
Diathermy is a therapeutic technique that produces
deep heating under the skin, muscles, and joints for
therapeutic purposes. It is classied into two types:
shortwave and microwave diathermy Recently, an elec-
tromagnetic diathermy has been introduced alongside
these categories. It is known as capacitive resistive
electric transfer and it can be considered as longwave

Andrzej Żyluk, Alicja Żyluk
2542
the mobility of the myofascial tissues adjacent to the
nerve. For CTS, the nerve gliding exercises are done
by alternately exion and extension of ngers with
dierent wrist positions and forearm in pronation and
supination [38, 39]. Tendon gliding exercises are done
by alternately exion and extension of all ngers and
thumb in metacarpophalangeal and interphalangeal
joints, making hook st, all nger joints in full exion
and full st [38, 39].
However, variability of manual techniques, lack of
terminology consensus and standardization in the
techniques whose aim is to mobilize the nervous
system raises doubts the actual eectiveness of these
techniques. Moreover, parameters such as the mobili-
zation dosages, the number of joints to be mobilized
and the consideration to stabilize or not the wrist joint
while performing the gliding mobilization techniques
are not uniform throughout the studies. These doubts
were highlighted in the study by Page et al. (2012) who
conducted a systematic review of studies presenting re-
sults of neural mobilization for carpal tunnel syndrome.
These authors concluded that there was limited and
very low quality evidence of benet for all of a diverse
collection of exercise and mobilisation interventions for
carpal tunnel syndrome. In most of reviewed studies
nerve mobilization techniques provided short-live im-
provement and only in mild CTS [40]. Therefore patients
who indicate a preference for exercise or mobilisation
interventions should be aware of the limited eective-
ness of this therapy.
KINESIOTAPING
Kinesiotaping is a therapeutic technique that pulls up
the skin and provides a space under the skin, directing
connective tissue to the expected area. Application of
this measure can control the pulling force to a certain
tendon or ligament to avoid further injury, so that
spontaneous tissue repair can be facilitated. It has been
hypothesized that kinesiotaping application, through
neural technique and space correction may be bene-
cial for patients with mild and moderate carpal tunnel
syndrome. Geler Kulcu et al. (2016) reported good
outcomes after use of kinesiotaping in 45 patients (65
wrists). The tape was applied at beginning of the week,
to stay on for 5 days, with a 2-day rest, for a total of
four times. At a nal follow-up, pain and paresthesiae
signicantly reduced and hand function signicantly
improved as assessed by Numeric Rank Scale and the
Boston Carpal Tunnel Questionnaire. The problem
with this study is that the authors did not provide the
follow-up period, therefore actual eect of this therapy
cannot be credibly evaluated [41]. In an another study, a
diathermy, as the wave frequency used is relatively
lower than those of shortwave and microwave. The
physiological eects of diathermy include an increase
in blood perfusion which facilitates tissue healing, a lo-
cal increase of oxygen and nutrients, improved muscle
contraction capacity, and a possible positive change in
pain sensation [36, 37]. Benecial eects of diathermy
could also be mediated at a central nervous system. Re-
sults of functional MRI studies showed central eects of
skin warming, with increased activation of the posterior
insula and thalamus of the brain which promoted pain
relief in the peripheral body parts [37].
Several studies are available investigating an eect
of diathermy in carpal tunnel syndrome.
Incebiyik et al., reported results of a randomized clin-
ical trial involving 31 CTS patients who were assigned
randomly to 2 treatment groups: rst received a hot
pack, shortwave diathermy, nerve and tendon gliding
exercises (treatment group) and second which received
a hot pack, placebo diathermy, nerve and tendon
gliding exercises (control group). The treatment was
applied ve times weekly for a total of 15 sessions. At
the one-month follow-up, improvement (cessation of
symptoms, better hand function) was observed in both
groups, however only in the treatment group it was
statistically signicantly better than at baseline [36].
Pollet et a., presented results of a systematic review
with meta-analysis on efficacy of electromagnetic
diathermy for the treatment of musculoskeletal disor-
ders, including CTS, based on 68 studies included in
the analysis. Many pathologies were treated with dia-
thermy against placebo. The analysed studies showed
controversial results and most of them did not show
signicant improvements in the primary outcomes.
The authors conclude that results of current evidence
does not conrm that diathermy or electromagnetic
diathermy can be considered an eective therapy in
musculoskeletal disorders, including CTS [37].
NEURAL MOBILIZATION
This method generally consists of techniques termed
neural glides, neural ossing or neural stretching.
The main objectives of neural mobilisation is to facili-
tate the gliding of tendons and nerves within the carpal
tunnel in order to maximize nerve and tendon excursion
to improve axonal transport and nerve conduction [38-
40]. Some joint mobilizations described as transverse
and ventral glide on dorsal side of the rst carpal row
were designed to release carpal tunnel syndrome by
increasing cross-sectional area of the carpal tunnel.
In addition, soft tissue mobilization aims to reduce
pressure on the carpal tunnel syndrome by improving

Eectiveness of non-operative methods of treatment of carpal tunnel syndrome: a narrative review
2543
indicates that only operative treatment by cutting the
exor retinaculum changes the anatomical relations in the
carpal tunnel and ensures a permanent cure. It is obvious
that surgery is burdened with a certain risk of complica-
tions, but this risk is disproportionately small in relation
to the benets achieved. Therefore, without denying the
legitimacy of non-surgical therapies in some patients and
in some situations, it must be clearly stated that scientic
evidence from reliable scientic publications clearly indi-
cates surgical treatment as ensuring permanent recovery
from the disease. Therefore, the statements sometimes
found in advertisements of some private clinics that one
of the new methods of non-surgical treatment is the same
eective as surgery, but without unpleasant adverse ef-
fects are unjustied and unfair.
benecial eect of kinesiotaping combined with splint-
ing was shown [42]. However, it should be stated that
this method, although simple and safe, is not popular as
a basic treatment and does not constitute a signicant
alternative to the previously discussed, much better
known techniques.
CONCLUSIONS
The review of non-operative treatments of CTS presented
in this paper indicates that each of the presented methods
provide only short-live improvement and none of them
provides a permanent cure. The multitude of these meth-
ods is only a conrmation of this fact. Current scientic
evidence on the eectiveness of various CTS treatments
REFERENCES
1. Bland JD. Carpal tunnel syndrome. BMJ. 2007 Aug 18;335(7615):343-6. doi: 10.1136/bmj.39282.623553.AD. DOI
2. Padua L, Coraci D, Erra C, et al. Carpal tunnel syndrome: clinical features, diagnosis, and management. Lancet Neurol. 2016 Nov;15(12):1273-
1284. doi: 10.1016/S1474-4422(16)30231-9. DOI
3. Puchalski P, Zyluk P, Szlosser Z, Zyluk A. Factors involved in the clinical prole of carpal tunnel syndrome. Handchir Mikrochir Plast Chir.
2018 Feb;50(1):8-13. doi: 10.1055/a-0572-7121. DOI
4. Żyluk A. Carpal tunnel syndrome in pregnancy: a review. Pol Orthop Traumatol. 2013 Oct 7;78:223-7.
5. Żyluk A. Is carpal tunnel syndrome an occupational disease? A review. Pol Orthop Traumatol. 2013 May 27;78:121-6.
6. Żyluk A, Szlosser Z. Ultra mini-invasive sonographically guided carpal tunnel release: a preliminary report. Chir Narzadow Ruchu Ortop
Pol., 2019; 84(5) 136-140. doi: 10.31139/chnriop.2019.84.5.28 DOI
7. Elsharif M, Papanna M, Helm R. Long-term follow up outcome results of Knifelight carpal tunnel release and conventional open release
following a departmental randomized controlled trial. A prospective study. Pol Orthop Traumatol. 2014 May 29;79:67-70.
8. Zyluk A, Skała K. Hand disorders in the course of systemic and chronic diseases: a review. Pol Orthop Traumatol. 2014 Apr 2;79:30-6.
9. Buntragulpoontawee M, Chang KV, Vitoonpong T, Pornjaksawan S, Kitisak K, Saokaew S, Kanchanasurakit S. The eectiveness and safety
of commonly used injectates for ultrasound-guided hydrodissection treatment of peripheral nerve entrapment syndromes: a systematic
review. Front Pharmacol. 2021 Mar 5;11:621150. doi: 10.3389/fphar.2020.621150 DOI
10. Lam KHS, Hung CY, Chiang YP, Onishi K, Su DCJ, Clark TB, Reeves KD. Ultrasound-guided nerve hydrodissection for pain management: rationale,
methods, current literature, and theoretical mechanisms. J Pain Res. 2020 Aug 4;13:1957-1968. doi: 10.2147/JPR.S247208 DOI
11. Lam KHS, Wu YT, Reeves KD, Galluccio F, Allam AE, Peng PWH. Ultrasound-guided interventions for carpal tunnel syndrome: a systematic
review and meta-analyses. Diagnostics (Basel). 2023 Mar 16;13(6):1138. doi : 10.3390/diagnostics13061138 DOI
12. Cass SP. Ultrasound-guided nerve hydrodissection: what is it? a review of the literature. Curr Sports Med Rep. 2016 Jan-Feb;15(1):20-2.
doi: 10.1249/JSR.0000000000000226 DOI
13. Yang FA, Wang HY, Kuo TY, Peng CW, Liou TH, Escorpizo R, Chen HC. Injection therapy for carpal tunnel syndrome: A systematic review and
network meta-analysis of randomized controlled trials. PLoS One. 2024 May 16;19(5):e0303537. doi: 10.1371/journal.pone.0303537 DOI
14. Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev. 2007 Apr
18;(2):CD001554. doi: 10.1002/14651858.CD001554.pub2. DOI
15. Ashworth NL, Bland JDP, Chapman KM, Tardif G, Albarqouni L, Nagendran A. Local corticosteroid injection versus placebo for carpal tunnel
syndrome. Cochrane Database Syst Rev. 2023 Feb 1;2(2):CD015148. doi: 10.1002/14651858.CD015148 DOI
16. Kaile E, Bland JDP. Safety of corticosteroid injection for carpal tunnel syndrome. J Hand Surg Eur Vol. 2018 Mar;43(3):296-302. doi:
10.1177/1753193417734426 DOI
17. Dong C, Zhu Y, Zhou J, Dong L, Hu L. Comparison of distal and proximal local steroid injection for carpal tunnel syndrome: a systematic review
and meta-analysis of randomized controlled trials. Pain Ther. 2022 Dec;11(4):1389-1402. doi: 10.1007/s40122-022-00444-3 DOI
18. Manente GTF, Di Blasio F, Staniscia T, Romano F, Uncini A. An innovative hand brace for carpal tunnel syndrome: a randomized controlled
trial. Muscle Nerve. 2001;24(8):1020-5. DOI
19. D eAngelis MV, Di Giovanni P, Staniscia T, Uncini A. Ecacy of a sof t hand brace and a wrist splint for carpal tunnel syndrome: a randomized
controlled study. Acta Neurol Scand. 2009;119(1):68-74. DOI

Andrzej Żyluk, Alicja Żyluk
2544
20. PageMJ, O’Connor D, Pitt V. Splinting for carpal tunnel syndrome. Cochrane Database Syst Rev. 2012;11(7):CD010003
21. Ostergaard PJ, Meyer MA, Earp BE. Non-operative treatment of carpal tunnel syndrome. Curr Rev Musculoskelet Med. 2020 Apr;13(2):141-
147. doi: 10.1007/s12178-020-09616-0. DOI
22. Lusa V, Karjalainen TV, Pääkkönen M, Rajamäki TJ, Jaatinen K. Surgical versus non-surgical treatment for carpal tunnel syndrome. Cochrane
Database Syst Rev. 2024 Jan 8;1(1):CD001552. doi: 10.1002/14651858.CD001552.pub3 DOI
23. Karjalainen TV, Lusa V, Page MJ, O’Connor D, Massy-Westropp N, Peters SE. Splinting for carpal tunnel syndrome. Cochrane Database Syst
Rev. 2023 Feb 27;2(2):CD010003. doi: 10.1002/14651858.CD010003.pub2 DOI
24. Çatalbas N, Akkaya N, Atalay NS, Sahin F. Ultrasonographic imaging of the eects of continuous, pulsed or sham ultrasound treatments
on carpal tunnel syndrome: A randomized controlled study. J Back Musculoskelet Rehabil. 2018;31:981-989.
25. Weintraub MI. Non-invasive laser neurolysis in carpal tunnel syndrome. Muscle Nerve. 1997 Aug;20(8):1029-31. doi: 10.1002/(sici)1097-
4598(199708)20:8<1029::aid-mus14>3.0.co;2-q DOI
26. Li ZJ, Wang Y, Zhang HF, Ma XL, Tian P, Huang Y. Eectiveness of low-level laser on carpal tunnel syndrome: A meta-analysis of previously
reported randomized trials. Medicine (Baltimore). 2016 Aug;95(31):e4424. doi: 10.1097/MD.0000000000004424. DOI
27. Ebenbichler GR, Resch KL, Nicolakis P, Wiesinger GF, Uhl F, Ghanem AH, Fialka V. Ultrasound treatment for treating the carpal tunnel
syndrome: randomised “sham” controlled trial. BMJ. 1998 Mar 7;316(7133):731-5. doi: 10.1136/bmj.316.7133.731 DOI
28. Page MJ, O’Connor D, Pitt V, Massy-Westropp N. Therapeutic ultrasound for carpal tunnel syndrome. Cochrane Database Syst Rev. 2013
Mar 28;2013(3):CD009601. doi: 10.1002/14651858.CD009601.pub2 DOI
29. Chung VCH, Ho RST, Liu S, Chong MKC, Leung AWN, Yip BHK. Electroacupuncture and splinting versus splinting alone to treat carpal
tunnel syndrome: A randomized controlled trial. Can. Med. Assoc. J. 2016, 188, 867-875. DOI
30. Li T, Yan J, Hu J, Liu X, Wang F. Ecacy and safety of electroacupuncture for carpal tunnel syndrome (CTS): A systematic review and
meta-analysis of randomized controlled trials. Front Surg. 2022 Sep 23;9:952361. doi: 10.3389/fsurg.2022.952361 DOI
31. Choi GH, Wieland LS, Lee H, Sim H, Lee MS, Shin BC. Acupuncture and related interventions for the treatment of symptoms associated
with carpal tunnel syndrome. Cochrane Database Syst Rev. 2018 Dec 2;12(12):CD011215. doi: 10.1002/14651858.CD011215.pub2 DOI
32. Ambroziak M. Application of ESWT in post-operative treatment in carpal tunnel syndrome – a review. Pol Przegl Chir. 2020 Apr 16;92(3):39-
43. doi: 10.5604/01.3001.0014.0947. DOI
33. Xu D, Ma W, Jiang W, Hu X, Jiang F, Mao C, Wang Y, Fang L, Luo N, Li H, Lou Z, Gan K. A randomized controlled trial: comparing extracorporeal
shock wave therapy versus local corticosteroid injection for the treatment of carpal tunnel syndrome. Int Orthop. 2020 Jan;44(1):141-
146. doi: 10.1007/s00264-019-04432-9 DOI
34. Kim JC, Jung SH, Lee SU, Lee SY. Eect of extracorporeal shockwave therapy on carpal tunnel syndrome: A systematic review and meta-
analysis of randomized controlled trials. Medicine (Baltimore). 2019 Aug;98(33):e16870. doi: 10.1097/MD.0000000000016870 DOI
35. Chen KT, Chen YP, Kuo YJ, Chiang MH. Extracorporeal shock wave therapy provides limited therapeutic eects on carpal tunnel syndrome:
a systematic review and meta-analysis. Medicina (Kaunas). 2022 May 19;58(5):677. doi: 10.3390/medicina58050677 DOI
36. Incebiyik S, Boyaci A, Tutoglu A. Short-term eectiveness of short-wave diathermy treatment on pain, clinical symptoms, and hand
function in patients with mild or moderate idiopathic carpal tunnel syndrome. J Back Musculoskelet Rehabil. 2015;28(2):221-8. doi:
10.3233/BMR-140507 DOI
37 . Pollet J, Ranica G, Pedersini P, Lazzarini SG, Pancera S, Buraschi R. The ecacy of electromagnetic diathermy for the treatment of musculoskeletal
disorders: a systematic review with meta-analysis. J Clin Med. 2023 Jun 9;12(12):3956. doi: 10.3390/jcm12123956 DOI
38. B ueno-Gracia E, Ruiz-de-Escudero-Zapico A, Malo-Urriés M, et al. Dimensional changes of the carpal tunnel and the median nerve during
manual mobilization of the carpal bones. Musculoskelet Sci Pract. 2018 Aug;36:12-16. doi: 10.1016/j.msksp.2018.04.002 DOI
39. Akalin EEO, Peker O, Senocak O, et al. Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises. Am J Phys Med
Rehabil. 2002;81(2):108-13. DOI
40. Page MJ, O’Connor D, Pitt V, Massy-Westropp N. Exercise and mobilisation interventions for carpal tunnel syndrome. Cochrane Database
Syst Rev. 2012 Jun 13;(6):CD009899. doi: 10.1002/14651858.CD009899 DOI
41. Geler Külcü D, Bursali C, Aktaş İ, Bozkurt Alp S, Ünlü Özkan F, Akpinar P. Kinesiotaping as an alternative treatment method for carpal
tunnel syndrome. Turk J Med Sci. 2016 Jun 23;46(4):1042-9. doi: 10.3906/sag-1503-4 DOI
42. Krause D, Roll SC, Javaherian-Dysinger H, Daher N. Comparative ecacy of the dorsal application of Kinesio tape and splinting for carpal
tunnel syndrome: A randomized controlled trial. J Hand Ther. 2021 Jul-Sep;34(3):351-361. doi: 10.1016/j.jht.2020.03.010 DOI
CONFLICT OF INTEREST
The Authors declare no conict of interest

Eectiveness of non-operative methods of treatment of carpal tunnel syndrome: a narrative review
2545
CORRESPONDING AUTHOR
Andrzej Żyluk
Klinika Chirurgii Ogólnej i Chirurgii Ręki
Pomorski Uniwersytet Medyczny,
ul. Unii Lubelskiej 1, 71-252, Szczecin, Poland
email: azyluk@hotmail.com
ORCID AND CONTRIBUTIONSHIP
Andrzej Żyluk: 0000-0002-8299-4525
Żyluk Alicja: 0009-0006-0309-0568
– Work concept and design, – Data collection and analysis, – Responsibility for statistical analysis, – Writing the article, – Critical review, – Final approval of the article
RECEIVED: 10.07.2024
ACCEPTED: 15.11.2024
CREATIVE COMMONS 4.0