What about steroids?

We recognize the desire to produce a “Five things to know about …” article for a common clinical condition. After all, the popular press constantly barrages us with similar entertaining lists of facts we didn’t know about certain things. Squissato and Brown1 have selected some interesting articles on which to comment from many thousands of possible articles. The danger of this approach was that it was completely at the discretion of the authors to select what they considered important topics and to hopefully then give an unbiased assessment of that topic. The article does not cite any of the 12 available Cochrane reviews on the topic of carpal tunnel syndrome.

For the most part, the article does a good job of simplifying the current knowledge. However, we take issue with point five regarding treatment of carpal tunnel syndrome. The authors based their recommendation on a small randomized-controlled trial comparing wrist splints and an educational program and a control group who received nothing.2 Perhaps not surprisingly, the control group experienced a dropout rate of over 22% compared to 3% in the treatment group. This obviously places the internal (and therefore external) validity in question. The study ultimately went on to show an advantage to the splint group. But why include this study in the first place when there is a Cochrane systematic review published just the year before that looked at 19 studies of wrist splints with almost 1200 patients enrolled?3

We have concerns about the recommendation to consult an occupational therapist for splinting. Wrist splints are available and inexpensive, and basic advice on activities to avoid is within the purview of the primary care practitioner. We suggest referral to an occupational therapist or orthotist only when over-the-counter splits don’t fit well (such as carpal tunnel syndrome associated with rheumatoid arthritis) to avoid delay in initiating treatment and additional expense.

More worrisome is Squissato and Brown’s1 conclusion that, “if symptoms do not improve within eight weeks, referral to a surgical specialist should be considered.” There is no evidence that eight weeks of splinting is the limit. This recommendation could lead to unnecessary surgical consultations. There is no mention of electrodiagnostic studies in the diagnosis and monitoring of the condition and no mention of the one treatment that has the best evidence of efficacy in carpal tunnel syndrome, corticosteroid injection.4