Is adding electroacupuncture on top of nocturnal splinting a better treatment option for carpal tunnel syndrome patients?
Date of publication of randomized controlled trial: June 2016
Design
Randomized controlled trial (RCT).
Participants
181 patients with carpal tunnel syndrome (CTS) who satisfied classic or probable criteria for CTS by Katz hand diagram and diagnosed as positive in at least 2 out of 3 clinical tests, namely Phalen maneuver test, Tinel sign test and the wrist flexion and median nerve compression test (electroacupuncture plus nocturnal splinting group: mean age: 51, male %: 14%; nocturnal splinting only group: mean age: 51±8.7 years, male %: 11%).
Intervention
Electroacupuncture was performed at eight acupoints: TW-5, PC-7, HT-3, PC-3, SI-4, LI-5, LI-10 and LU-5 on the affected side. After all acupoints were inserted with needles, electro-stimulation was immediately applied in the combination of (i) TW-5 + PC-7, (ii) SI-4 + LI-5, (iii) LI-10 + LU-5, and (iv) HT-3 + PC-3. Duration of each treatment lasted for 20 minutes. The total number of sessions was 13 over 17 weeks. One 10-minute education on the use of wrist splint was first provided for patients and they were advised to use the splint for 8 hours every evening during the study period. Patients with bilateral CTS received treatment on both sides.
Comparator
Comparison: Electroacupuncture plus nocturnal splinting versus noncturnal splinting alone. Identical prefabricated wrist splint and the 10-minute education on the use of splint was provided for patients in the group of noncturnal splinting alone.
Major Outcomes
Outcome 1: Mean difference change in Symptom Severity Scale (SSS) score of the Boston Carpal Tunnel Questionnaire from baseline to week 17;
Outcome 2: Mean difference change in Functional Status Scale (FSS) score of the Boston Carpal Tunnel Questionnaire from baseline to week 17;
Outcome 3: Mean difference change in Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) score from baseline to week 17;
Outcome 4: Mean difference change in Dellon-Modified Moberg Pick-Up Test (DMMPUT) from baseline to week 17;
Outcome 5: Mean difference change in maximal tip pinch strength from baseline to week 17.
Settings
The trial was conducted in outpatient settings.
Comparison    Electroacupuncture with nocturnal splinting versus nocturnal splinting
Main Results
Compared to patients in nocturnal splinting only group, patients who received electroacupuncture along with nocturnal splinting experienced greater improvements at week 17 on the following outcomes: SSS score of the Boston Carpal Tunnel Questionnaire (mean difference [MD]: -0.20, 95% confidence interval [CI]: -0.36 to -0.03), FSS score of the Boston Carpal Tunnel Questionnaire (MD: -0.22, 95% CI: -0.38 to -0.05), DASH score (MD: -6.72, 95% CI: -10.9 to -2.57), time to complete DMMPUT (MD: -6.13 seconds, 95% CI: -10.6 to – 1.63) and maximal tip pinch strength (MD: 1.17 lb, 95% CI: 0.48 to 1.86).
Comparison: Electroacupuncture with nocturnal splinting versus nocturnal splinting among patients with carpal tunnel syndrome
Outcomes (units) No. of studies (Total number of participants) Mean change from baseline / No. of participants Heterogeneity test (I2) MD (95% CI) p value Overall quality of evidence*
Intervention Comparator
1 (NA) 1 (181) -0.25/ 90 -0.09/ 91 Not applicable as there is only 1 trial -0.20 (-0.36 to -0.03) 0.02 Moderate
2 (NA) 1 (181) -0.16 /90 0.02/ 91 Not applicable as there is only 1 trial -0.22 (-0.38 to -0.05) 0.01 Moderate
3 (NA) 1 (181) -7.75 / 90 -1.53 / 91 Not applicable as there is only 1 trial -6.72 (-10.9 to -2.57) <0.01 Moderate
4 (s) 1 (181) -6.50/ 90 -0.32/ 91 Not applicable as there is only 1 trial -6.13 (-10.6 to -1.63) <0.01 High
5 (lb) 1 (181) 1.75/ 90 0.52/ 91 Not applicable as there is only 1 trial 1.17 (0.48 to 1.86) <0.01 Very high
Keys: MD: mean difference; CI: confidence interval.
Comparison    Electroacupuncture with nocturnal splinting versus nocturnal splinting
Main Results
Compared to patients in nocturnal splinting only group, patients who received electroacupuncture along with nocturnal splinting experienced greater improvements at week 17 on the following outcomes: SSS score of the Boston Carpal Tunnel Questionnaire (mean difference [MD]: -0.20, 95% confidence interval [CI]: -0.36 to -0.03), FSS score of the Boston Carpal Tunnel Questionnaire (MD: -0.22, 95% CI: -0.38 to -0.05), DASH score (MD: -6.72, 95% CI: -10.9 to -2.57), time to complete DMMPUT (MD: -6.13 seconds, 95% CI: -10.6 to – 1.63) and maximal tip pinch strength (MD: 1.17 lb, 95% CI: 0.48 to 1.86).
Comparison: Electroacupuncture with nocturnal splinting versus nocturnal splinting among patients with carpal tunnel syndrome
Outcomes (units) 1 (NA) 2 (NA) 3 (NA) 4 (s) 5 (lb)
No. of studies (Total number of participants) 1 (181) 1 (181) 1 (181) 1 (181) 1 (181)
Mean change from baseline / No. of participants Intervention -0.25/ 90 -0.16 /90 -7.75 / 90 -6.50/ 90 1.75/ 90
Comparator -0.09/ 91 0.02/ 91 -1.53 / 91 -0.32/ 91 0.52/ 91
MD (95% CI) -0.20 (-0.36 to -0.03) -0.22 (-0.38 to -0.05) -6.72 (-10.9 to -2.57) -6.13 (-10.6 to -1.63) 1.17 (0.48 to 1.86)
p value 0.02 0.01 <0.01 <0.01 <0.01
Overall quality of evidence* Moderate Moderate Moderate High Very high
Keys: MD: mean difference; CI: confidence interval.
Conclusion
Benefits
Compared to nocturnal splinting alone, electroacupuncture can provide improvements in symptoms, function, disability, dexterity and pinch strength up to 17 weeks when combined with nocturnal splinting among patients with chronic mild to moderate symptoms of primary CTS. For outcomes 1, 2 and 3, the overall quality of evidence is moderate. Further research is fairly likely to have an important impact on our confidence in this estimate of effect. For outcome 4, the overall quality of evidence is high. Further research is unlikely to have an important impact on our confidence in this estimate of effect. For outcome 5, the overall quality of evidence is very high. Further research is most unlikely to have an important impact on our confidence in this estimate of effect.
Harms
Four patients (4.4%) reported bruising at acupoints, three (3.3%) mentioned mild local dermatitis around the treatment sites, two (2.2%) complained of increased pain, and two (2.2%) reported numbness and tingling after electroacupuncture treatment. All adverse events resolved within a week.
Link to Original Article
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5008933/
The synopsis is based on the following article:
Chung VC, Ho RS, Liu S, Chong MK, Leung AW, Yip BH, Griffiths SM, Zee BC, Wu JC, Sit RW, Lau AY. Electroacupuncture and splinting versus splinting alone to treat carpal tunnel syndrome: a randomized controlled trial. Canadian Medical Association Journal. 2016 Sep 6;188(12):867-75.


* Interpretation of quality assessment results:
• Very low: Further research is most likely to have an important impact on our confidence in this estimate of effect.
• Low: Further research is likely to have an important impact on our confidence in this estimate of effect.
• Moderate: Further research is fairly likely to have an important impact on our confidence in this estimate of effect.
• High: Further research is unlikely to have an important impact on our confidence in this estimate of effect.
• Very high: Further research is most unlikely to have an important impact on our confidence in this estimate of effect.

Details of assessment method can be found at Chung VC, Wu XY, Ziea ET, Ng BF, Wong SY, Wu JC. Assessing internal validity of clinical evidence on effectiveness of CHinese and integrative medicine: Proposed framework for a CHinese and Integrative Medicine Evidence RAting System (CHIMERAS). European Journal of Integrative Medicine. 2015 Aug 31;7(4):332-41.