Low-dose, short-term oral prednisone in the treatment of carpal tunnel syndrome

Herskovitz, Steven; Berger, Alan R.; Lipton, Richard B.

doi:10.1212/wnl.45.10.1923

Cited by 75 publications

(50 citation statements)

References 2 publications

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“…3 NO. 13 oral steroids [101][102][103] and therapeutic ultrasound, 104,105 and limited evidence (findings from one RCT) for the effectiveness of yoga 106 and carpal bone mobilisation. 107 Evidence from a second Cochrane systematic review 108 indicated that local corticosteroid injections provided greater improvement in clinical symptoms after 1 month than placebo injections.…”

Section: Overview Of Evidence On Non-surgical Interventionsmentioning

confidence: 99%

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Hollingworth

Rooshenas

Busby

et al. 2015

Health Services and Delivery Research

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BackgroundNHS expenditure has stagnated since the economic crisis of 2007, resulting in financial pressures. One response is for policy-makers to regulate use of existing health-care technologies and disinvest from inefficiently used health technologies. A key challenge to disinvestment is to identify existing health technologies with uncertain cost-effectiveness.ObjectivesWe aimed to explore if geographical variation in procedure rates is a marker of clinical uncertainty and might be used by local commissioners to identify procedures that are potential candidates for disinvestment. We also explore obstacles and solutions to local commissioners achieving disinvestment, and patient and clinician perspectives on regulating access to procedures.MethodsWe used Hospital Episode Statistics to measure geographical variation in procedure rates from 2007/8 to 2011/12. Expected procedure numbers for each primary care trust (PCT) were calculated adjusting for proxies of need. Random effects Poisson regression quantified the residual inter-PCT procedure rate variability. We benchmarked local procedure rates in two PCTs against national rates. We conducted rapid systematic reviews of two high-use procedures selected by the PCTs [carpal tunnel release (CTR) and laser capsulotomy], searching bibliographical databases to identify systematic reviews and randomised controlled trials (RCTs). We conducted non-participant overt observations of commissioning meetings and semistructured interviews with stakeholders about disinvestment in general and with clinicians and patients about one disinvestment case study. Transcripts were analysed thematically using constant comparison methods derived from grounded theory.ResultsThere was large inter-PCT variability in procedure rates for many common NHS procedures. Variation in procedure rates was highest where the diffusion or discontinuance was rapidly evolving and where substitute procedures were available, suggesting that variation is a proxy for clinical uncertainty about appropriate use. In both PCTs we identified procedures where high local use might represent an opportunity for disinvestment. However, there were barriers to achieving disinvestment in both procedure case studies. RCTs comparing CTR with conservative care indicated that surgery was clinically effective and cost-effective on average but provided limited evidence on patient subgroups to inform commissioning criteria and achieve savings. We found no RCTs of laser capsulotomy. The apparently high rate of capsulotomy was probably due to the coding inaccuracy; some savings might be achieved by greater use of outpatient procedures. Commissioning meetings were dominated by new funding requests. Benchmarking did not appear to be routinely carried out because of capacity issues and concerns about data reliability. Perceived barriers to disinvestment included lack of collaboration, central support and tools for disinvestment. Clinicians felt threshold criteria had little impact on their practice and that prior approval systems would not be cost-effective. Most patients were unaware of rationing.ConclusionsPolicy-makers could use geographical variation as a starting point to identify procedures where health technology reassessment or RCTs might be needed to inform policy. Commissioners can use benchmarking to identify procedures with high local use, possibly indicating overtreatment. However, coding inconsistency and limited evidence are major barriers to achieving disinvestment through benchmarking. Increased central support for commissioners to tackle disinvestment is needed, including tools, accurate data and relevant evidence. Early engagement with patients and clinicians is essential for successful local disinvestment.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Section: Overview Of Evidence On Non-surgical Interventionsmentioning

confidence: 99%

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Hollingworth

Rooshenas

Busby

et al. 2015

Health Services and Delivery Research

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“…The longterm differences between the groups could not be evaluated, because only patients who improved after 4 weeks were assessed after 6 months. The low quality study [25] evaluated the effect of an oral steroid.After 2 weeks there was significantly more improvement in symptoms in the steroid group, compared with the placebo group, but this effect had disappeared after 4 and 8 weeks.…”

Section: Other Types Of Oral Medicationsmentioning

confidence: 99%

Conservative treatment options for carpal tunnel syndrome: a systematic review of randomised controlled trials

Gerritsen¹,

Krom

Struijs³

et al. 2002

Journal of Neurology

185

122

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“…16,18 Of the RCTs on surgical techniques 7 RCTs compared endoscopic carpal tunnel release with open carpal tunnel release (OCTR), 19 -26 3 RCTs evaluated the effect of OCTR with a new incision technique versus OCTR with a standard incision, 27-30 and 3 RCTs compared OCTR with additional internal neurolysis with OCTR alone. [31][32][33][34] Data presentation in the RCTs concerning conservative treatment options for CTS was generally adequate.…”

Section: Resultsmentioning

confidence: 99%

“…The most commonly used outcome measures were those related to symptoms of CTS. A wide variety of those measures were used including the following: specific descriptions of symptoms (eg, pain, paraesthesias), 11,13 more general expressions (eg, night discomfort or just symptoms), 10,14 combinations of symptoms (eg, night/day pain/paraesthesias, global symptom score), 13,16,18 measures relating to improvement of symptoms (eg, symptoms improved/changed/worsened), 15 or severity of symptoms (eg, main complaints: no complaints at all [0] to the most intense complaints I can imagine [10]). 12 Because pooling of heterogeneous outcomes will lead to an uninterpretable and misleading pooled estimate, meta-analysis is not feasible.…”

Section: Resultsmentioning

confidence: 99%

“…12 Because pooling of heterogeneous outcomes will lead to an uninterpretable and misleading pooled estimate, meta-analysis is not feasible. Only the 2 trials concerning the efficacy of oral steroids 16,18 used the same outcome measure, but unfortunately only one 16 adequately reported means and SDs. Two of the other outcome measures (distal motor latency and distal sensory latency) were considered to be sufficiently similar, but this was only a very small subset of all outcomes used and in our opinion not the most important ones.…”

Section: Resultsmentioning

confidence: 99%

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Enabling meta-analysis in systematic reviews on carpal tunnel syndrome

Gerritsen

Vet

Scholten

et al. 2002

The Journal of Hand Surgery

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Possible solutions to the problems of clinical heterogeneity of outcome measures and inadequate reporting of results for randomized controlled trials (RCTs) on carpal tunnel syndrome (CTS) are presented. Meta-analysis was impeded by these problems in 2 systematic reviews concerning conservative and surgical treatment options for CTS. A solution to the problem of inadequate data presentation is to add explicit information on minimal requirements with regard to data presentation to guidelines for the reporting of studies. To resolve the problem of clinical heterogeneity of the outcomes there should be consensus on the (validated) outcomes that should be used in RCTs. For CTS there is little evidence available on the reliability, validity, and responsiveness to change of the commonly used outcomes in RCTs.Resolving both problems will increase the comparability of RCTs, enabling the calculation of a pooled estimate of effect in a meta-analysis. Systematic reviews of high-quality, randomized controlled trials (RCTs) are considered to be the highest level of evidence in research concerning medical interventions. 1 To quantify the effect of the various treatment options, preferably a meta-analysis is performed. By combining individual study results a precise estimate of the magnitude of the treatment effect can be obtained. Meta-analysis is, therefore, an important part of a systematic review. Meta-analysis is only feasible if RCTs are clinically homogeneous, that is, if the patients, interventions, comparisons, outcomes, and timing of follow-up measurements are sufficiently similar. 2 Randomized controlled trials, however, may use a range of different outcome measures. 3,4 Another prerequisite for combining study results is adequate and uniform data presentation. Reporting of results in biomedical journals is often inadequate. 5,6 This article presents possible solutions to the problems of clinical heterogeneity of the outcome measures and inadequate reporting of results for RCTs on carpal tunnel syndrome (CTS). First we show, however, that meta-analysis was impeded by these problems in 2 systematic reviews concerning conservative and surgical treatment options for CTS. 7,8

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Low-dose, short-term oral prednisone in the treatment of carpal tunnel syndrome

Cited by 75 publications

References 2 publications

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Conservative treatment options for carpal tunnel syndrome: a systematic review of randomised controlled trials

Enabling meta-analysis in systematic reviews on carpal tunnel syndrome

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