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: [email protected]).
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
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15. White A, Hayhoe S, Hart A, et al. Survey of adverse events
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