Rapid Responses to:

LETTERS: Louis Deliss Ultrasound treatment for carpal tunnel syndrome BMJ 1998; 317: 601 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Varying Degrees of Carpal Tunnel Syndrome

Erik Dombroski   (28 September 1998)

Treatment for carpal tunnel syndrome

P Thomas Davis   (1 October 1998)

Emphasis must be on return of sensation and function

Luca Padua   (21 October 1998)

Varying Degrees of Carpal Tunnel Syndrome 28 September 1998
Erik Dombroski, Physiotherapy Clinical Educator School of Physiotherapy, AIT, Auckland, New Zealand Send response to journal: Re: Varying Degrees of Carpal Tunnel Syndrome	Dr. Deliss, Consultant hand and orthopaedic surgeon response to Ebenbichler et al study has some worthy points in regards to sensation and function. However as stated by Dr. Deliss, "..as a hand surgeon I see many patients who are permanently disabled by end stage carpal tunnel syndrome"; we must remember that these patients are exactly that, "end- stage". Physiotherapists predominately see patients with mild to moderate symptoms. It is in these cases as rightly pointed out by Gerold R Ebenbichler that the question arises is there justifiable grounds to subject these patients to a surgical procedure when conservative treatment may suffice? If costs are the underlying factor, 20 visits (at $20 NZ per visit)is still far lower than any surgical procedure if a comparable long-term outcome can be proven.
Treatment for carpal tunnel syndrome 1 October 1998
P Thomas Davis Send response to journal: Re: Treatment for carpal tunnel syndrome	Dear Editor We have read with interest and concern both Dr. Gerold Ebenbichler's article and the comments of Dr. Louis Deliss. We have completed at least one clinical trial on CTS comparing two conservative treatments with a one -month follow-up. For reference this appeared in the Journal of Manipulative and Physiological Therapeutics in June, 1998 and was entitled, Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: a randomized clinical trial, P. Thomas Davis, et al. In the environment of managed health care in the US presently, effective and cost effective conservative treatments are encouraged, certainly from the primary care area. We disagree with Dr. Deliss that most cases of CTS need to be treated surgically. We do agree, however, that research on the outcomes of non- surgical treatment must assess longer-term follow-up. Our recent research was limited to one month follow-up, but we are planning further study including a follow-up assessment of pain sensation and function at 3, 6 and 12 months post randomization. The research referred to above, did find that both medical and chiropractic management reduced pain and increased function for patients with mild and moderate CTS. Cases screened and noted as severe were referred for further neurological evaluation. We do thank Dr. Deliss for the Ebenbichler citation. Sincerely P. Thomas Davis, MUP, DC Associate Professor, Clinical Research James R. Hulbert, PhD Northwestern College of Chiropractic Bloomington, Minnesota USA
Emphasis must be on return of sensation and function 21 October 1998
Luca Padua Send response to journal: Re: Emphasis must be on return of sensation and function	We read the article by Ebenbichler on ultrasound therapy in Carpal Tunnel Syndrome (CTS) and the subsequent controversial reply by Deliss (1,2) with great interest. We think that this debate discloses some of the most important problems of recent studies: the significance of the outcome measures used and the knowing the natural history of the pathologies. The study by Ebenbichler is a well conducted study that evaluates the effect of a non surgical therapy of CTS. The assessment is faithful and multiprospective even though more complete tools are now available to measure the patient-oriented outcome. On the other hand, Deliss replies, without reporting data and based on clinical experience, that the management of CTS with a non-definitive cure could by very dangerous. Therefore the authors do not use the same measure. We take the title of the reply ("emphasis must be on return of sensation and function") as a starting point for underlining that a modern and specific tool that well assesses the symptom and the function of the patient affected by CTS is available. Levine (3) has developed a validated patient-oriented measurement obtained by a self-administered questionnaire which evaluates two domains of CTS: "symptoms" and "functional status". We have validated the Italian version (4) and using it in multiprospective studies (patient-, physician- and neurophysiological-oriented), we have recently obtained interesting and reliable data (4,5). Concerning the fear of Deliss, we agree that in more severe cases a reduction of symptoms occurs simultaneously to the loss of median nerve function, but until now no studies have described a rapid and progressively catastrophic course of idiopathic mild-moderate CTS. The problem is that the knowledge of the natural course of any disease has a significant clinical and therapeutic implication and, although CTS is a common disease, the natural history of this nerve entrapment has rarely been described. We think that the validated outcome measures now available are reliable and that multiprospective assessment of the pathologies which include modern patient-oriented measurement may provide faithful results. Moreover, using these tools, data obtained from different studies (for example evaluation of different therapies) will be comparable. Therefore, by speaking a unique language and possibly using the same "meter", the debates will be more useful and will help doctors practice better medicine (as stated by BMJ's aim). Luca Padua MD PhD 1,2,3 , Roberto Padua MD4, Irene Aprile MD1 and P. Tonali MD1 1 Institute of Neurology, 4 Institute of Orthopaedics - Università Cattolica - Roma 2 CRCCS - AFaR Osp. Fatebenefratelli Isola Tiberina - Roma 3 Fondazione Pro Iunventute, Don C. Gnocchi - Roma References 1 Ebenbichler GR, Resch KL, Nicolakis P, Wiesinger GF, Uhl F, Ghanem A-H, et al . Ultrasound treatment for treating the carpal tunnel syndrome: randomised "sham" controlled trial. BMJ 1998;316:731-5. (7 March.). Dellis L. Emphasis must be on return of sensation and function BMJ 1998;317:601. (29 August.) 2 Levine DW, Simmons BP, Koris MJ, Daltroy LH, Hohl GG, Fossel AH, Katz JN. A self-administreted Questionnaire for the assessment of severity of simptoms and functional status in carpal tunnel syndrome. J Bone Joint Surg 1993;75A: 1585-92. 3 Padua R, Romanini E, Zanoli G. Analisi dei risultati nell'apparato locomotore. Milano: Guerini e Associati Ed., 1998. 4 Padua L, Padua R, Aprile I and Tonali P. "Noninvasive laser neurolysis in carpal tunnel syndrome". Muscle and Nerve 1998; 9: 1232-33.