Microsoft word - 07_djmcj_alam_m_efficacy.doc

Original Contribution
Efficacy of Short-term Low Dose Oral Steroid in Carpal Tunnel Syndrome
*Alam MM,1 Bari MS,2 Ullah AK,3 Haque A,4 Sardar AH,5 Mohammad KD6 To determine the efficacy of four weeks course of oral steroid in the conservative treatment of idiopathic mild to moderate carpal tunnel syndrome this observational study was carried out in the department of neurology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka from January to December 2005. A total of 60 patients with carpal tunnel syndrome were randomly divided in two treatment groups. One group of 30 patients designated as case treated with oral steroid. Initial two weeks 20 mg oral prednisolone, next two weeks 10 mg oral prednisolone with Omeprazole 20 mg twice daily for 4 weeks. Another 30 patients who were clinically and electrophysiologically as CTS treated with physiotherapy. A symptoms questionnaire was used to determine the five major symptoms of carpal tunnel syndrome (numbness, pain, weakness/clumsiness, tingling, and nocturnal awakening) on a scale of 0 (nil) to 10 (severe); The resulting global symptom score was used to evaluate the efficacy of treatment. Assessments were made at baseline and at one month. Electro-diagnosis was repeated at the end of the study to validate improvement. After treatment with short-term low dose oral prednisolone GSS improved in 56.3% and electrophysiological parameters showed significant improvement in all measured. It may be concluded that low dose short-term oral prednisolone is an effective treatment of idiopathic carpal tunnel syndrome. [Dinajpur Med Col J 2008 Jul; 1 (2):33-39] Key words: Carpal tunnel syndrome, steroids.
Introduction
disturbance and even economic loss by job C mediun nerve at the wrist (Carpal 1. *Dr. Md. Mahbubul Alam, Assistant tunnel) in absence of an obvious injury, Professor, Department of Neurology, treatment or surgery. This is the commonest neuropathy.1,2,3 Women are three times more 2. Dr. M Saiful Bari, Associate Professor, Department of Cardiology, Dinajpur Medical College, Dinajpur, Bangladesh intermittent tingling paresthesia of the palmar 3. Professor Dr. AKM Anwar Ullah, Professor, aspect of the first three and half digits and Department of Neurology, BSMMU, Dhaka, lateral two thirds of the hand of the affected side. The dominant hand is usually affected 4. Professor Dr. Anisul Haque, Professor, first and produces the most severe pain.4 As Department of Neurology, BSMMU, Dhaka, the disease progress, This tingling becomes more continuous and ultimately wasting of 5. Dr. Abdul Halim Sardar, Assistant Professor, the thenar eminence and weakness of the grip. Department of Neurology, Khulna Medical The known associated conditions and disease for CTS are female sex, obesity, pregnancy, 6. Professor Dr. Kazi Din Mohammad, and acromegaly, hypothyroidism, rheumatoid Professor, Department of Neurology, Dhaka Medical College, Dhaka, Bangladesh. arthritis, repeated use of vibrating hand tolls, Original Contribution
disturbance. So, early diagnosis and treatment Control: Subjects who were diagnosed
are important to avoid permanent damage of clinically and ecletrophysiologically as CTS the mediun nerve. There are many therapeutic Sample size: There were two groups of
conservative including avoiding excess use of hand, use of splint, oral steroid, local steroid, designated as control and another group of 30 diuretics, oral pyridoxine, NSAIDS, therapy patients designated as cases. Both the groups etc. It is noted that approximately 80% of were match in respects do age and sex CTS patients with CTS initially responds with measures, surgery is the approach of choice, Sample size determination: Sample size of
older patients and factors, such as poor mental this study was determined purposively by the health, significant alcohol consumption longer researcher considering all resource constrains disease duration and male gender, poorer like limited time, financial support and outcome after surgery. This study was aimed at to find a) the response of low dose short term oral steroid in mild to moderate carpal Sampling
technique:
conducted by using convenient type of non tingling, numbness, nocturnal awakening, weakness and clumsiness symptoms of carpal tunnel syndrome c) the improvement of NCS Inclusion Criteria:
(Nerve conduction –study) parameters such as Clinical: a) Symptoms of CTS for more than
latency, difference between the medium and ulnar motor and sensory distal latency of symptoms e) positive Tinel’s sign and phalen This was an observational study. This study man cover f) absence of any of the exclusion Electrophysiological: a) medium sensory
Bangladesh. This study was done in one year distal latency more than 3.1 ms. (Millisecond) b) medium motor distal latency more than 4.4 ms. c) difference between distal motor latency of medium and ulnar nerve more than 1.1 ms. Case: Patient attending the out door of
d) difference between distal sensory latency of medium and ulnar nerve more then 0.2 ms designated as clinically suspected CTS and Exclusion Criteria: a) symptoms less than 3
parameters and treated for 4 weeks with oral months b) CTS like conditions, e.g. cervical radiculopathy, proximal medium neuropathy or significant polyneuropathy c) exclusion of prednisolone , and omeprazole 20 mg twice hypothyroidism, diabetes mellitus, pregnancy, vibrating users d) cognitive impairment interfering with subjects to follow instructions Original Contribution
and describe symptoms e) recent peptic ulcer clumsiness (10%). In control group it was (86.7%) nocturnal awakening (63.3%), pain Data Collection tools:
Questionnaire: Both groups of subjects were collected by structured questionnaire of five major symptoms of CTS such as a) numbness b) pain c) weakness /clumsiness d) tingling e) Table II shows the global symptoms score of both hands in case and control groups. Their Scale: O (Nil) to 10 (Severe) - according to comparison and significant of difference are GSS, CTS is classified into mild, moderate also given. Analysis shows that there was significant percent chance from before to after treatment (right side case 56.98% and control 30.66% left side: Cases 54.3% and control 25.72%) with P-value of <0.001 in both case and control groups which were significant. assessment was made at baseline and at one of both hands in case and control groups. month. Electro diagnosis was repeated at the end of the study to validate improvement. difference are also given. Analysis shows that there was significant percent chance from Diagnostic Criteria for CTS:
before to after treatment (MN - MDL- right Diagnostic criteria for CTS was set as the side; case 10.68% and control 4.9%; Left side following a) medium sensory distal latency > – case –10.43% and control 10.26%), MN - 3.1 ms. b) medium motor distal latency > 4.4 SDL - right side case 13.98 % and control ms. c) difference between distal motor latency of medium and ulnar nerve > 1.1 ms. d) diffeence between distal latency of medium Table IV shows the difference between the case and control groups. Their comparison Table I shows the distribution of symptoms of and significance of differences are also given. case and control groups before and after Analysis shows that there was significant treatment. Tingling of the hands was found to percent change from before to after treatment (right side : case –30.22% and control 5.6%; 93.3% in case and 96.7% in control groups. Left side – case 29.28 and control 7.28%) After treatment it was 60% in case and 76.7% with P value of < 0.001 in both case and before treatment in case group; numbness (90%), pain (73.3%), nocturnal awakening Table VI shows the significance between MN SDL and UN SDL of both hands in case and (33.3%) and after treatment in case group; significance of difference are also given. Analysis shows that there was significant Original Contribution
percent chance from before to alter treatment with p- value of <0.001 in both case and (right side case 26.27% and control 9.62%; control group a which were significant . Left side; cases 29.2% and control 9.17% Table I: Symptoms of the subjects before and after treatment. Table II: Treatment response on global symptom score in case (N=30) and control (N=30) groups Paired students ‘+’ test *** = Significant. Original Contribution
Table III: Treatment response on nerve conduction study – MN-MDL and MN-SDL of both upper limbs in case (N=30) and control (N=30) groups. MN MDL (ms) Paired Students “+” test *** = Significant. Table IV: Treatment response on nerve conduction study difference between MN – MDL and UN MDL of both upper limbs in case-(N=30) and control (N=30) groups Paired Students “+” test **/ *** = Significant. Original Contribution
Table V: Treatment response on nerve conduction study- difference between MN SDL and UN SDL of both upper limbs in case (N=30) and control (N=30) groups Paired Students “+” test
**/ *** = Significant.
Paired students ‘+’ test
*** = Significant.
Discussion
clumsiness (10%), presenting symptoms of carried outs to see whether the low dose numbness (87.7%), pain (63.3%), Nocturnal steroid is effective in the treatment of carpal tunnel syndrome. The study subjects were weakness (20%) and after treatment it was electrophysiological testing in the department nocturnal awakening score after low dose oral socioeconomic status matched respondents of This study shows that the global symptoms score (GSS) had significant percent change from before to after 4 week treatment with Table I of this study shows that most common low dose oral prednisolone( right case-56.3%, symptoms of CTS was tingling of the hand; in cnotrol-30.66%) Left case- 56.3%, control case, it was 93.3% and control 96.7%. After 25.72%). Similar studies showed that the GSS treatment it was 60% in case and 76.7% in improved in 66%.7,8 The difference between control 76.7% in control. This result is quite this study and those of above studies may be consistent with that of the study done by 7 due to small number of study population. clumsiness (36.7%) and weakness (33.3%) in from before to after treatment (MN- MDL- right side case –10.68% and control-4.9%; Left side cases-10.43% and control 10.26%); Original Contribution
control-4.45%). This observation suggest that prednisolone is effective in mild to moderate 4. Reinstein L. Hand dominance in carpal MN-SDL in 4 weeks prednisolone group.7,8 The present study shows that the difference 5. O’ Decffy JD, Randall RV, Mac Carly SDL and UN-SDL of both hands in case and tunnel syndrome) in acromegaly; a sign of control groups there was significant percent change from before to after treatment similar studies showed significant improvement of Studies are effective at reducing swelling on account of their anti-inflammatory action considering all the above observations it is established that this study showed that oral steroid (prednisolone) in the treatment oral 7. Herskovitz S Berger AR, Lipton RB. Low mild to moderate carpal tunnel syndrome is dose, short term oral prednisolone in the It may be concluded that low dose short term SY, 2002. A randomised clinical trial of oral prednisolone is an effective treatment of oral steroids in the treatment of carpal idiopathic carpal tunnel syndrome. But this tunnel syndrome; A long term follow up: J study has some limitations ie regarding long References
1. Kimncera J. Electrodiagnosis in diseases practices, 2nd ed philadelphia ; FA Davis 2. Murthy, JMK, Meena AK. Carpal tunnel syndrome; elcetrodiagnostic as pects of fifty seven synptomatic hands Neurol India, 1999;47: 272-5, DR. Early diagnosis of carpal tunnel syndrome ; comparison of digit, with wrist

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