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Acupuncture in Patients With Carpal Tunnel Syndrome Chun-Pai Yang, MD,*w z Ching-Liang Hsieh, MD, PhD,w y Nai-Hwei Wang, MD,Jz Tsai-Chung Li, PhD,z# Kai-Lin Hwang, MSc, ** Shin-Chieh Yu, MD,* and (P = 0.012). Acupuncture was well tolerated with minimal adverse Objectives: To investigate the efficacy of acupuncture compared with steroid treatment in patients with mild-to-moderate carpaltunnel syndrome (CTS) as measured by objective changes in nerve Conclusions: Short-term acupuncture treatment is as effective asshort-term low-dose prednisolone for mild-to-moderate CTS. For conduction studies (NCS) and subjective symptoms assessment in a those who do have an intolerance or contraindication for oral steroid or for those who do not opt for early surgery, acupuncture Methods: A total of 77 consecutive and prospective CTS patients treatment provides an alternative choice.
confirmed by NCS were enrolled in the study. Those who had fixedsensory complaint over the median nerve and thenar muscle Key Words: acupuncture, carpal tunnel syndrome, CTS, steroid, atrophy were excluded. The CTS patients were randomly divided into 2 treatment arms: (1) 2 weeks of prednisolone 20 mg daily followed by 2 weeks of prednisolone 10 mg daily (n = 39), and (2)acupuncture administered in 8 sessions over 4 weeks (n = 38). Avalidated standard questionnaire as a subjective measurement wasused to rate the 5 major symptoms (pain, numbness, paresthesia,weakness/clumsiness, and nocturnal awakening) on a scale from 0 Carpal tunnel syndrome (CTS), which results from the (no symptoms) to 10 (very severe). The total score in each of the 5 compression of the median nerve at the wrist, can be categories was termed the global symptom score (GSS). Patients caused by many different factors. Any condition that reduces completed standard questionnaires at baseline and 2 and 4 weeks the dimensions of the tunnel or increases the volume of its later. The changes in GSS were analyzed to evaluate the statistical content will predispose individuals to CTS, and many significance. NCS were performed at baseline and repeated at the medical associations have been reported (ie, diabetes mellitus, end of the study to assess improvement. All main analyses used renal failure, thyroid disease, rheumatoid arthritis), but most cases are idiopathic.1–3 The typical symptoms of CTS includesensory impairments, such as numbness or pain in the wrist, Results: A total of 77 patients who fulfilled the criteria for mild-to- hand and fingers, which often occur during sleep and awaken moderate CTS were recruited in the study. There were 38 in the CTS patients occasionally. Shaking or rubbing the hands acupuncture group and 39 in the steroid group. The evaluation of usually relieves the symptoms. The motor symptoms of CTS GSS showed that there was a high percentage of improvement in include weakness of the thenar muscle, and loss of hand both groups at weeks 2 and 4 (P<0.01), though statistical dexterity and function. Both objective and subjective symptoms can occur unilaterally or bilaterally. The best (P = 0.15). Of the 5 main symptoms scores (pain, numbness, way to confirm the diagnosis is to carry out a median nerve paresthesia, weakness/clumsiness, nocturnal awakening), only 1, conduction study (NCS) across the transverse carpal nocturnal awakening, showed a significant decrease in acupuncture ligament. A characteristic of the condition is a focal compared with the steroid group at week 4 (P = 0.03). Patients conduction slowing in NCS across the wrist segment.3–5 with acupuncture treatment had a significant decrease in distal Many conservative treatments are commonly used in motor latency compared with the steroid group at week 4 mild and moderate CTS. For these patients, short-termnonsurgical management may be desirable and may reducethe number of patients undergoing surgical intervention.
Received for publication May 25, 2008; revised September 14, 2008; Among the conservative treatments, there is strong evidence that local corticosteroid injections, and to a lesser From the Departments of *Neurology; JOrthopedics, Kuang Tien extent oral corticosteroids, provide short-term relief for General Hospital; wGraduate Institute of Acupuncture Science; CTS sufferers.6,7 In addition, splints are effective, especially Graduate Institute of Chinese Medical Science, College of Chinese if used full time6,7; however, many CTS patients report that yChinese Medicine, China Medical University Hospital; **Depart- splinting restricts hand activity and hinders their ability to ment of Public Health, Chung Shan Medical University; zHuang- work or perform daily activities.8 Local steroid injections Kuang University; wwSection of Neurology, Taichung Veterans into the carpal tunnel may result in initial relief, but General Hospital, Taichung; and zzDepartment of Neurology,National Yang-Ming University, Taipei, Taiwan.
relapses are frequent, and mechanical or chemical nerve injury can occur.7,8 Oral steroids are better than nonsteroid Reprints: Ming-Hong Chang, MD, Section of Neurology, Veterans anti-inflammatory drugs and diuretics, but they can General Hospital, No 160, Chung-Kang Road, Section 3, produce side effects, which preclude their routine use for Taichung, Taiwan, 40705 (e-mail: cmh50@ms10.hinet.net).
Copyright r 2009 by Lippincott Williams & Wilkins CTS.7 Acupuncture is a complementary medical technique Clin J Pain  Volume 25, Number 4, May 2009 Clin J Pain  Volume 25, Number 4, May 2009 used for the treatment of painful disorders. However, at (Daling), PC-6 (Neiguan)] on the affected side in their 8 present, there is no conclusive evidence of the efficacy of sessions without modification for the specific symptoms of acupuncture in treatment of CTS.6,8 In an attempt to the patients. We placed patients in the supine position to investigate whether acupuncture is as effective and safe as make them more comfortable. Sterile disposable steel steroid in the treatment of mild-to-moderate CTS, we needles (gauge and size: 0.25 Â 40 mm) were used without conducted a prospective, randomized clinical study under electrical stimulation or moxibustion. At each point, the skin was wiped with alcohol and needles were insertedperpendicularly at PC-6 to a depth of 1.0 to 1.5 inch and atPC-7 they were inserted from 0.5 to 1.0 inch according to the thickness of the patient’s wrist. The needles were The study protocol was approved by the institutional manipulated by twirling with lifting-thrusting methods to produce a characteristic sensation known as De Qi (anawareness of numbness, soreness, swelling, heaviness, or radiating feeling from the point of needling deemed to The patients, aged from 18 to 85, enrolled in this study indicate proper needle position and effective needling) and had clinical symptoms and signs of CTS. CTS was were then left in place for 30 minutes. For patients with diagnosed clinically based on the presence of at least one bilateral CTS, both wrists were needled and data were of the following primary symptoms: (1) numbness, tingling pain, or paresthesia in the median nerve distribution; (2) However, we included only the more-affected hand precipitation of these symptoms by repetitive hand activ- with a higher GSS in each individual for data analysis. As ities, which could be relieved by resting, rubbing, and only 1 hand with a higher GSS score from each individual shaking the hand; and (3) nocturnal awakening by such was used for analysis, the number of participants was equal sensory symptoms. The diagnosis was often supported by a to the number of affected arms enrolled in the analysis set.
positive Tinel sign. All patients with clinically diagnosed All treatments were performed at the same facility by 1 CTS demonstrated median neuropathy at the wrist, acupuncturist. Additionally, the acupuncturist was asked to confirmed by the presence of 1 or more of the following have the least possible communication with patients to standard electrophysiologic criteria: (1) prolonged distal minimize bias. Complete details of the intervention are motor latency (DML) to the abductor pollicis brevis (APB) presented in Table 1 in conformance to the standards for (abnormal Z4.7 ms, stimulation over the wrist, 8 cm reporting interventions in controlled trial of acupuncture.13 proximal to the active electrode); (2) prolonged antidromicdistal sensory latency (DSL) to the second digit (abnormal Z 3.1 ms; stimulation over the wrist, 14 cm proximal to theactive electrode); and (3) prolonged antidromic wrist-palm sensory nerve conduction velocity (W-P SNCV) at a The median and ulnar nerves were studied with no distance of 8 cm (W-P SNCV, abnormal <45 m/s).9–12 If abnormality in the ulnar nerves. Motor and sensory NCS the patients fulfilled the criteria and gave written informed were performed using standard techniques of supramaximal consent before randomization, they were enrolled in the percutaneous stimulation and surface electrode recording.
study. Possible side effects were fully explained. At their DML and DSL, motor nerve conduction velocity, com- first visit, we assessed their medical and neurologic history, pound muscle action potential (CMAP), sensory nerve gave them detailed physical and neurologic examinations, action potential (SNAP) amplitudes, and W-P SNCV were biochemical and endocrine screenings (ie, fasting blood measured using the methods described by Delisa et al.9 The sugar, thyroid stimulating hormone, free T4), NCS andneedle electromyography. Before treatment, the patientswere followed-up for 1 month. If improvement occurredduring observational periods, patients were excluded from TABLE 1. Standards for Reporting Interventions in Controlled this study. After enrollment, the patients were randomized into 2 treatment arms: (1) a group receiving 2 weeks of 20 mg prednisolone daily followed by 10 mg daily for another 2 weeks; and (2) a group receiving acupuncture in 8 sessions over 4 weeks. The randomization was carried out according to computer-generated randomly allocated treat- ment codes and data were kept by a person not involved in Depth of insertion: standard to each point the care or evaluation of the patients or in the data analysis.
All patients received complete global symptom score (GSS) measurements at baseline, 2, and 4 weeks and NCS at baseline and 4 weeks later performed by the same blinded evaluator throughout the entire study period. All patients were scheduled so as to avoid any overlap during which they could share clinical information and experiences with Acupuncture consisted of 8 sessions of 30-minute duration, administrated over 4 weeks (2 sessions/wk). Each patient had fixed and classic acupuncture points [PC-7 Clin J Pain  Volume 25, Number 4, May 2009 Acupuncture in Patients With Carpal Tunnel Syndrome electromyographic recording (Viking IV; Nicolet WI, improvement, we repeated NCS at the end of the Madison, WI) of motor conduction studies were made assessment for those patients who completed the study.
with the filter band pass at 2 to 10 Hz, a sweep speed of But for the patients lost to follow-up and those who 2 ms/cm, and the amplifier gain adjusted for full reviewing received surgery, we decided not to repeat the NCS.
of the CMAP. For measurement of SNAP, the instrument Additional treatments (such as splinting and local injec- settings were: filters, 20 Hz to 10 kHz; sweep, 2 ms/cm; gain, tions) or alterations in daily activities were not permitted Patients were excluded if any of the following were present: (1) symptoms occurring less than 3 months before the study or symptoms improving during the 1-month Patients reported all serious adverse events with side initial observation period (to exclude patients who might effects of both oral steroids treatment at weeks 2 and 4 and have spontaneous resolution of symptoms); (2) severe CTS acupuncture treatment in each session. We recorded that had progressed to visible muscle atrophy; (3) in our adverse side effects such as nausea, epigastric pain, tarry study, mild CTS referred to patients with decreased stools, leg edema, cushingoid appearance, blood pressure, conduction velocity over the palm-wrist segment and blood sugar along with ecchymosis, local paresthesia, or delayed DSL, with normal median SNAP amplitude and bleeding to treat analysis for all enrolled patients.
CMAP amplitude of the APB. Moderate CTS referred topatients with abnormally delayed DML and DSL with either decreased median SNAP amplitude or decreasedCMAP amplitude of the APB muscle. Thus, CTS patients A last-observation-carried-forward approach was used with the presence of either fibrillation potentials or to input missing data with the intent-to-treat analysis reinnervation on needle EMG in the APB were excluded principle. Independent 2-sample t test was performed to (to ensure the inclusion of only mildly or moderately compare the efficacy of the objective changes in nerve affected individuals); (4) clinical or electrophysiologic conduction and subjective symptoms assessment between evidence of accompanying conditions that could mimic the 2 groups for the baseline, 2-week and 4-week evalua- CTS or interfere with its evaluation, such as cervical tions. Repeated measures analysis of variance with Bon- radiculopathy, proximal median neuropathy, or significant ferroni adjustment for multiple testing was used to compare polyneuropathy; (5) evidence of obvious underlying causes the changes in subjective symptoms assessment between of CTS such as diabetes mellitus, rheumatoid arthritis, week 2 or 4 data and baseline data within each treatment hypothyroidism (acromegaly), pregnancy, alcohol abuse or group. Paired t test was performed for objective changes in drug usage (steroids or drugs acting through the central nerve conduction between week 4 data and baseline data nervous system), use of vibrating machinery, and suspected within each treatment group. For 5 main symptoms score malignancy or inflammation or autoimmune disease were of GSS and 6 measures of NCS, Bonferroni adjustment was documented as underlying causes for CTS; (6) recent peptic made to control for type I error. All hypothesis testing were ulcer or history of steroid intolerance; (7) prior unpleasant 2-tailed and level of significance was set at 0.05. All experience with acupuncture or a bleeding diathesis; or (8) statistical analyses were performed using SPSS Version 15.0 cognitive impairment interfering with the patient’s ability to for Windows (SPSS Inc, Chicago, IL).
follow instructions and describe symptoms.
Clinical assessments included the symptomatic ques- tionnaire modified from that used by Herskovitz et al14 and A total of 77 patients who fulfilled the inclusion and by us in our previous study.10,11 We rated symptoms from 0 exclusion criteria agreed to participate in our study and (no symptoms) to 10 (very severe symptoms) in each of 3 were randomly allocated to either the steroid or acupunc- categories: pain, numbness, and paresthesia. Nocturnal ture treatment group. The baseline characteristics of the 2 awakening was scored by times awakened in 1 week: never, groups were similar in the intention-to-treat population 0; once or twice, 2; 3 or 4 times, 4; 5 to 7 times, 6; 8 to 10 (Table 2). Of the 77 patients, 3 patients in the acupuncture times, 8; more than 10 times, 10. Weakness was scored group dropped out due to inability to take time off work, according to the severity of the weakness: none, 0; mild, 2; and 4 patients in the steroid group did not finish the study moderate, 3; severe, 4; very severe, 5; and assessed for due to intolerance of side effects of epigastric pain with clumsiness by difficulty in manipulating small objects: none, nausea. No patients received surgery before the end of the 0; mild, 2; moderate, 3; severe, 4; very severe, 5. The total ofthe scores of the 5 main symptoms was the GSS. Eachpatient was directly questioned, and each score was basedon the patient’s subjective answers. Therefore, the maxi- TABLE 2. Summary of Baseline Characteristics of Study Patients mum score was 50 (most severe symptoms) and the minimum score was 0 (absence of symptoms). Furthermore, to ensure consistency, the evaluating physician was the same person on each occasion for each patient. Follow-up assessments identical to the baseline procedure were At the end of the study, neurologic examinations were Values are number or mean (standard deviation, SD).
repeated, along with the same biochemical and endocrine examinations as at baseline. To obtain objective evidence of Clin J Pain  Volume 25, Number 4, May 2009 Fulfill inclusion and exclusion criteriaN=90 Excluded becausepatients were notinterested or difficultto find time to FIGURE 1. Flow chart of process and disposition of patients.
study. The dropout rate was low for both the steroid and significant difference between the 2 groups before treat- acupuncture groups. We substituted baseline values for the ment. At the end of the study, there was a high percentage missing data of the 7 patients who did not complete the of improvement in both the acupuncture and steroid groups study (thus, setting differences compared with baseline to at weeks 2 and 4 (all P<0.01 for both groups), though zero). Figure 1 illustrates patient enrollment and random statistical significance was not achieved between the 2 allocation of patients to study groups. There was no groups (P = 0.15) (Fig. 2A). Of the 5 parameter scores difference in age, sex, or duration of symptoms between (pain, numbness, paresthesia, weakness/clumsiness, noctur- nal awakening), only 1, nocturnal awakening showed asignificant decrease between the 2 groups. Patients with acupuncture treatment had significantly better improve- Table 3 shows the changes in GSS for the 77 patients ment in nocturnal awakening compared with the steroid who were available for the efficacy analysis. There was no group at week 4 (P = 0.03) (Fig. 2B).
TABLE 3. Cumulative Data of Global Symptom Score (GSS) Changes wWeek 2 or 4—baseline/baseline.
zP <0.05 after Bonferroni adjustment.
Values are mean (standard deviation, SD).
Clin J Pain  Volume 25, Number 4, May 2009 Acupuncture in Patients With Carpal Tunnel Syndrome by 5% of the patients. Most adverse effects were related to the local insertion of the needles, such as local pain after session, ecchymosis, and local paresthesia during session.
Acupuncture was well tolerated by patients and no one discontinued prematurely because of needle-related sideeffects. In the steroid treatment group, the most frequently noted adverse effects were nausea and epigastralgia. Sideeffects from steroid were reported by 18% of the patients.
Four patients dropped out due to intolerance of severeepigastralgia with nausea.
The present study is one of the most rigorous trials of the efficacy of acupuncture treatment versus proven standard drugs on CTS available. Its strength includes interventions based on expert consensus by qualified and experienced medical acupuncturists, assessment of the credibility of interventions, and outcome measurements asrecommended in guidelines for trials on CTS. The results of the current study showed that there was a high percentageof improvement in both groups at week 4 with subjectivemeasurement of GSS, though statistical significance was not achieved between the 2 groups. Furthermore, patientswith acupuncture treatment had significantly better im-provement in the main symptoms score of nocturnal awakening compared with the steroid group at week 4. Inthe assessment with objective measurement of NCS, patients with acupuncture treatment had significantly better improvement in DML compared with the steroid group atweek 4. It can be concluded that acupuncture treatment had at least equal, and in some cases, superior efficacy when compared with steroid treatment not only in objective changes in nerve conduction but also in subjective symptoms assessment. However, the disadvantage of Change from Baseline of Nocturnal Awakening acupuncture is that it is time-consuming.
Several large surveys have also provided evidence that acupuncture is a relatively safe treatment.15–18 Acupuncture FIGURE 2. A, Change of total global symptom score for treatments were well tolerated by our patients. Indeed, most acupuncture and steroid groups over time. A significant patients found participation in the study to be pleasant and difference from baseline for weeks 2 and 4 were observed by rewarding. Needle-related side effects like bruising and repeated measures analysis of variance for both groups soreness were more common in the acupuncture group than (P<0.01);**P< 0.01 (B) Change of nocturnal awakening foracupuncture and steroid groups over time. A significant in the steroid group, but these were mild and did not affect difference between acupuncture and steroid groups at week 4 treatment. No patient withdrew due to adverse effects.
was observed (P<0.05) by independent 2-sample t test.
However, in the steroid group, 4 patients dropped out due to intolerance of severe epigastralgia with nausea. Somemight ask why patients with acupuncture treatment had Table 4 illustrates the outcome and severity of NCS significant improvement not only in objective changes in findings including DML, CMAP amplitude of APB muscle, NCS but also in subjective symptoms assessment. Acu- motor nerve conduction velocity, DSL, W-P SNCV, and puncture treatment is an invasive manual procedure; thus, SNAP amplitudes of median nerves before and after separating the specific effects from nonspecific effects is treatment in both groups. There was no significant extremely difficult.19 Various neurophysiologic and psycho- difference between the 2 groups before treatment. After physiologic mechanisms underlying the analgesic effective- treatment, there was a significant decrease in DML and ness of acupuncture have been hypothesized.19 However, DSL, and a significant increase in W-P SNCV and SNAP even though acupuncture therapy has been used exten- amplitudes within each treatment group (P<0.05) for both sively, its mechanisms of action in CTS are not precisely steroid and acupuncture groups. In addition, there was known, in part because the pathophysiology of CTS itself is significantly increased CMAP amplitude of the APB muscle not well understood. CTS etiology is thought to involve in the steroid group (P<0.05). Patients with acupuncture compression of the distal median nerve due to an elevated treatment had significantly better improvement in DML interstitial fluid pressure in the carpal tunnel. Ischemic compared with steroid group at week 4 (P = 0.012) (Fig. 3).
injury and mechanical deformity of the median nerveproduced by elevated pressure within the carpal tunnel leads to anoxic capillary damage, which in turn leads to No serious adverse effects were noted. In the increased membrane permeability, exudative edema, and acupuncture treatment group, side effects were reported subsequent fibrosis.14,20–22 Steroids are effective at reducing Clin J Pain  Volume 25, Number 4, May 2009 TABLE 4. Improvement in Electrodiagnostic Measurements in Patients With Carpal Tunnel Syndrome who had Symptom Relief Electrodiagnostic Variable, With Normal Result *P<0.05 compared with baseline within group by paired t test with Bonferroni adjustment.
wThe change from baseline was compared between groups with independent t test.
Values are mean (standard deviation, SD).
CMAP indicates compound muscle action potential; DML, distal motor latency; DSL, distal sensory latency; MNCV, motor nerve conduction velocity; NS, non-significant; SNAP, sensory nerve action potential; W-P SNCV, wrist-palm sensory nerve conduction velocity.
swelling because of their anti-inflammatory action. It is thus Furthermore, if both treatments are possibly effective, it is reasonable to use oral steroids in the treatment of CTS and easy to explain and encourage patients to be recruited in a short-term course of low-dose steroids can be of great current study. Recently, a Japanese study found that most people in Asian countries have knowledge about acupunc- CTS.10,12,13,23,24 A recent study suggests that acupuncture ture and have received acupuncture treatment, and 60% of may possess anti-inflammatory action via release of the patients could distinguish between sham and genuine neuropeptides from nerve endings.25 There is also evidence needling.30 Our patients were also able to make this that acupuncture processing in the brains of CTS patients distinction, so we did not choose sham acupuncture in differs from that of healthy controls.26 It would be of great our study. Steroid treatment is one of the most common interest to know what roles the peripheral and the central used drugs in clinical practice for treatment of mild-to- mechanisms play in CTS patients after acupuncture moderate CTS. But in our society, most people are treatment, although it is beyond the scope of this article.
reluctant to take it. So, we set out to answer the clinically In traditional Chinese medical literature, the acupuncture relevant question, ‘‘does acupuncture improve outcomes point Neiguan has been shown to relieve insomnia.27 This among patients with mild-to-moderate CTS comparable to may explain why patients who received acupuncture steroid treatment?’’ This is substantially different from the treatment had significantly better improvement in noctur- question, ‘‘does acupuncture improve outcomes compar- nal awakening compared with the steroid group at week 4.
able to a sham procedure that appears to be similar to, but The investigators are aware of and capable of using isn’t really, acupuncture?’’ Therefore, an active instead of sham acupuncture28,29; however, the reason for our placebo control was used in this study, and the steroid preference for an active drug rather than placebo was less treatment for CTS was chosen as a comparison.
ethical problem to adopt an active treatment arm for The natural history in CTS patients was not well patients who looked for a treatment for their discomforts.
characterized until a recent study by Padua et al.31 In theirstudy of 441 hands afflicted with idiopathic CTS, theyfound that 21% of hands improved over 10 to 15 months offollow-up without active intervention. Thus any therapeutic intervention should attempt to achieve a better than 21% accepted in Taiwan and oral steroid is considered as an alternative conservative in previous studies.10,12,13,23,24 Though there is no real placebo group in current study, however, a placebo effect or spontaneous resolution would have been less likely to occur due to the patients’ more than 21% improvement in GSS in both groups. In addition, there was improvement in the objective measures, NCS, in patients after acupuncture and steroid treatment. Further- more, in 1 previous study, nearly a quarter of the patientshad relief of symptoms within the first month of initial assessment.32,33 To decrease this confounding effect, anypatient whose symptoms occurred less than 3 months before the study or whose symptoms improved during the first observation period was excluded from current study.
Only 4 patients had marked relief of symptoms during the observation period and they were excluded.
Although we conclude that short-term acupuncture FIGURE 3. Change from baseline of motor distal latency (DML)between acupuncture and steroid groups by independent treatment is an effective and safe treatment for symptom- atic relief in CTS, some questions remain unanswered: Clin J Pain  Volume 25, Number 4, May 2009 Acupuncture in Patients With Carpal Tunnel Syndrome 1. Is acupuncture therapy effective for long-term symptom tional conduction techniques in electro diagnosis of carpal tunnel syndrome. Clin Neurophysiol. 2006;117:984–991.
2. Do symptoms recur once acupuncture is discontinued, 13. MacPherson H, White A, Cummings M, et al. Standards for and is further acupuncture therapy effective in patients reporting interventions in controlled trials of acupuncture: theSTRICTA recommendations. J Altern Complement Med. 2002; 3. What is the mechanism of acupuncture on CTS? 14. Herskovitz S, Berger AR, Lipton RB. Low-dose, short-term To answer these questions, we are currently conduct- oral prednisone in the treatment of carpal tunnel syndrome.
ing other studies. Future studies may also consider additional assessments using validated commonly used 15. White A, Hayhoe S, Hart A, et al. Survey of adverse events disability scales such as the SF-36, Disability of Arm, following acupuncture (SAFA): a prospective study of 32,000 Shoulder and Hand questionnaire to make comparison of consultations. Acupunct Med. 2001;19:84–92.
the data to other published literature more relevant.
16. Melchart D, Weidenhammer W, Streng A, et al. prospective investigation of adverse effects of acupuncture in 97733patients. Arch Inter Med. 2004;164:104–105.
17. Yamashita H, Tsukayama H, Hori N, et al. Incidence of adverse reactions associated with acupuncture. J AlternComplement Med. 2000;6:345–350.
Despite the limitations, this randomized, controlled 18. Witt C, Brinkhaus B, Jena S, et al. Acupuncture in patients with study indicates that short-term acupuncture treatment is as osteoarthritis of the knee: a randomized trial. Lancet. 2005;366: effective as short-term low-dose steroid for mild-to-moder- ate CTS. For those who do not tolerate oral steroid or for 19. Cabyoglu MT, Ergene N, Tan U. The mechanism of those who do not opt for surgery, acupuncture treatment Acupuncture and clinical applications. Int J Neurosci. 2006; provides an alternative choice. We now need to assess the long-term effects of acupuncture on mild-to-moderate CTS 20. Werner RA, Andary M. Carpal tunnel syndrome: pathophysio- logy and clinical neurophysiology. Clin Neurophysiol. 2002;113: 21. Keir PJ, Rempel DM. Pathomechanics of peripheral nerve loading. Evidence in carpal tunnel syndrome. J Hand Ther.
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