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Carpal Tunnel Syndrome

Extracorporeal shock wave therapy (ESWT) is a noninvasive carpal tunnel syndrome treatment option that has been gaining attention as a potential alternative for mild to moderate carpal tunnel syndrome.

Carpal tunnel syndrome (CTS), the most common entrapment neuropathy, results from compression of the median nerve within the carpal tunnel. This compression leads to a variety of symptoms, including paresthesia, pain, and impaired hand function, significantly impacting an individual's daily activities and quality of life. While surgical interventions are available, conservative treatments are often preferred, especially for cases of mild to moderate CTS. Extracorporeal shockwave therapy (ESWT) has emerged as a promising non-invasive treatment option.

Traditional Treatments for CTS

Traditional approaches to managing CTS encompass both non-surgical and surgical methods:

• Wrist Splinting: This involves wearing a brace or splint, particularly at night, to maintain the wrist in a neutral position. By doing so, pressure on the median nerve is reduced.
• Medications: Including oral corticosteroids or non-steroidal anti-inflammatory drugs.
• Physical Therapy: Including therapeutic ultrasound, low level laser therapy, transcutaneous electrical nerve stimulation, contrast baths, tendon and nerve gliding exercises.
• Steroid Injections: Local corticosteroid injections directly into the carpal tunnel can provide temporary relief by reducing inflammation. However, steroid injections and surgery always carry some risks of side effects (e.g. infections or allergic reactions).
• Activity modification: Changing working conditions with reducing repetitive movements.

Despite the availability of these treatment options, their efficacy has been shown in many cases to be either insignificant or short-lived. Many studies revealed that using extracorporeal shock wave therapy (ESWT) has a long‑term effect on the pain improvement raised from soft tissue disorders such as plantar fasciitis and Achilles, shoulder and elbow tendinopathy.

What is ESWT?

ESWT involves the application of acoustic waves to the affected tissue, stimulating metabolic activity and promoting tissue remodeling. These acoustic waves interact directly with cells by mechanotransduction, activating the metabolic rate which leads to tissue remodeling. This therapy is characterized by a high peak pressure, rapid pressure increase, short duration, and energy density ranging from 0.003 to 0.89 mJ/mm. ESWT can be classified into two main types:

• Focused ESWT (fESWT): This type delivers the maximum energy to a specific point located deeper within the tissue.
• Radial ESWT (rESWT): rESWT has a more superficial effect, dispersing energy radially at the skin's surface. Radial shock wave has more advantages than focused shock wave due to the large treatment area.

How ESWT Works

ESWT exerts its therapeutic effects through various mechanisms, including pain relief, anti-inflammatory action, and nerve regeneration:

• It is assumed that the therapeutic effect of ESWT acts in two ways; induction of anesthesia in nerve fibers by biomechanical changes and reducing the inflammation of soft tissues.
• ESWT stimulates the production of nitric oxide (NO), which has anti-inflammatory and vasodilatory effects, helping to reduce pain transmission in the nervous system.
• It promotes angiogenesis and neurogenesis through the release of vascular endothelial growth factor (VEGF), enhancing blood supply and nerve regeneration in the treated area.
• ESWT can stimulate the elasticity of the transverse carpal ligament via mechanotransduction effects and therefore relieve the CTS symptoms.
• ESWT reduces calcitonin gene–related peptide (CGRP) with accompanying anti-inflammatory effects in the median nerve and its surrounding soft tissue.
• Acoustic stimulation of living tissues seems to influence the complex nitric oxide pathway, which is able to modulate inflammation by an angiogenic and trophic effect.
• It promotes tenocyte proliferation and collagen synthesis, aiding in tissue repair and remodeling.

Effectiveness of ESWT for CTS

Numerous studies have provided evidence supporting the effectiveness of ESWT in the treatment of CTS:

• Pain Reduction: ESWT has been shown to significantly reduce pain levels, as measured by the Visual Analog Scale (VAS).
• Functional Improvement: Patients undergoing ESWT have demonstrated improvements in handgrip strength and overall hand function.
• Nerve Conduction: fESWT can lead to improved sensory nerve conduction velocity and distal motor latency of the median nerve.
• Symptom Relief: ESWT has demonstrated significantly greater improvement in visual analogue scale (VAS) and the Boston carpal tunnel syndrome questionnaire (BCTQ) scores.
• Long-term effects: ESWT can lead to longer-term effects among mild-to-moderate CTS patients.
• ESWT is a valuable and practical treatment modality without serious side effects, as well as reduces pain, neuropathic symptoms, disability, and improves electrophysiological findings in patients with mild-to-moderate CTS.

Vahdatpour et al. (2016) showed significant pain reduction after ESWT, comparable to local corticosteroid injections, though electrodiagnostic assessments did not show significant improvement. Another study (Gesslbauer et al., 2021), however, showed significantly greater improvement in VAS, BCTQ, and cross-sectional area (CSA) of the median nerve. Radial shockwave combined with conventional physiotherapy is also effective in treating mild to moderate CTS with longer lasting results than conventional physiotherapy alone.

Study Parameters for ESWT

The parameters for ESWT application can vary, as different studies have employed different settings:

• fESWT: One study (Gesslbauer et al., 2021) utilized a linear fESWT device (therapy source FBL 10X5G2, PiezoWave2) delivering 500 shocks at an energy flux density (EFD) of 0.05mJ/mm2 at a pulse repetition frequency of 4Hz, administered once a week for 3 weeks.
• rESWT: A study (Habibzadeh et al., 2022) used low-energy shockwaves with 1,500 shocks at a pressure of 1.5 bar and a rate of 6 pulses per second, applied perpendicularly on the patient’s palm over the median nerve on the carpal tunnel.

Potential Benefits

ESWT offers several potential advantages over traditional treatments for CTS:

• Non-invasive: As a non-surgical option, ESWT avoids the risks associated with injections and surgery.
• Safe: ESWT is generally safe and well-tolerated, with few reported side effects.
• Effective: Studies have demonstrated significant improvements in pain, function, and nerve conduction.

The effect of ESWT on pillar pain after carpal tunnel release

Pillar pain, which is known as the pain between the thenar and hypothenar areas of the hand, is reported as the most common complication after surgical treatment of CTS. The results of one study (Haghighat et al. 2019) revealed that hand function and pain score in patients with pillar pain after carpal tunnel release improved faster in those who received ESWT compared to control patients. Therefore, because of the noninvasive nature of ESWT, it can be a useful technique for improvement of pillar pain in patients with CTS.

ESWT presents a promising avenue as an effective and safe non-invasive treatment for mild to moderate CTS. Further research is warranted to optimize treatment parameters, assess long-term efficacy, and elucidate the precise mechanisms underlying its therapeutic effects.

...But what if my carpal tunnel is severe?

• Traditional Surgical Release: In severe cases or when conservative measures fail, traditional surgical techniques known as the open and/or mini-open carpal tunnel release may be performed. This involves cutting the transverse carpal ligament to relieve pressure on the median nerve. Surgical complications comprising structural damage to the nerves, arteries, and tendons are rare and based on traditional surgical methods reported between 0.19% and 0.5%. Pillar pain, scar tenderness, transient neuropraxia, and reoperation are among the other common complications of surgical treatment of CTS and can result in delayed return to work (4-6 weeks) and cause decline of health‑related quality of life.
• Guo Technique: A newer ultra-minimally invasive sono-surgical technique invented by Drs. Danzhu and Danqing Guo can be used to surgically release the transverse carpal ligament without injury to the flexor retinaculum or other vital structures utilizing thread, which decreases the return to work time of 1-2 days, leaves no scar, eliminates incidents of pillar pain and can be performed in as little as 10 minutes in office or an ambulatory surgical center. Dr. Thomas trained under the Guo brothers and is the only physician in Michigan and one of few physicians around the world that can perform the technique.

...But what if I previously had carpal tunnel surgery and still have tingling and burning sensations?

• Scrambler Therapy: Scrambler therapy is a treatment that is 80-90% effective for neuropathic pain like carpal tunnel syndrome, but also conditions such as complex regional pain syndrome/reflex sympathetic dystrophy (CRPS/RSD), chemotherapy-induced neuropathy, diabetic neuropathy, and phantom limb syndrome. Using an advanced four-phase neuromodulation algorithm frequency, this therapy sends synthetic 'non-pain' signals through skin electrodes to retrain your brain's perception of pain, leveraging your brain's ability to reform neural connections (neuroplasticity). The treatment is safe, drug-free, and requiring no surgery. Scrambler Therapy can significantly reduce pain intensity and improve your quality of life through a series of sessions tailored to your specific needs. Thomas Sports and Regenerative Orthopedics is Scrambler Certified and offers the ONLY 3rd generation scrambler model in the State of Michigan—because living in pain shouldn't be the only option.

If you have experienced numbness, tingling and/or burning in your thumb, index finger, and middle finger for more than 6 weeks, call Thomas Sports and Regenerative Orthopedics for the most advanced treatments of carpal tunnel syndrome.

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